Table 2

New chronic care model for integrated primary care of HIV and diabetes in sub-Saharan Africa

Model componentPerson-centred formulationHealthcare service delivery strategiesThemes from expanded thematic framework
Improve patient access to care.‘I am able to access the chronic disease care I need’.Routine chronic care delivery is decentralised to a primary care level to improve patient access.
Streamlined and coordinated processes are developed and implemented to improve efficiency of patient services.
Available healthcare staff are effectively used through rational shifting of tasks and have clearly defined roles and responsibilities for delivering integrated chronic care.
Strategies to reduce patient out-of-pocket expenditure for care and medications are developed.
New theme of ‘patient access’
New theme of ‘task shifting’
Foster patient–provider partnerships.‘I partner with my healthcare worker to improve my health’.Patient–healthcare worker communication that facilitates information exchange and shared decision-making is developed and encouraged.
Healthcare worker training promotes the importance of patient-centred chronic care.
Service design and implementation safeguard patient confidentiality and seeks to reduce chronic disease stigma.
Patients are consulted and involved in the planning and implementation of healthcare services.
Effective avenues of feedback are provided for patient suggestions, concerns and complaints.
Care provided is appropriate to the patient’s cultural background.
New theme of ‘patient–provider partnerships’
New theme of ‘stigma and confidentiality’
A priori theme of ‘effective team-working to deliver continuity and coordinated proactive care’
Ensure patient safety and care quality.‘I receive safe, high-quality healthcare’.Organisational leadership develops a culture that supports and promotes the improvement in quality of patient care.
Effective strategies are promoted for improving the quality of patient care.
Information for monitoring and evaluation of team performance is collected and used to drive improvements in patient care.
Providing quality care for patients is incentivised.
Quality monitoring and improvement activities are routine among all team members.
Processes are in place for the review of significant events to improve patient safety.
A priori theme of ‘organisational leadership, culture and mechanisms to promote quality and safety’
A priori theme of ‘use of data collection systems to facilitate effective care and follow-up’
Empower patients for self-care.‘I am empowered with the information and resources to manage my health’.Patients are empowered to take a central role in managing their care.
Proactive support is provided for patient self-management and prevention efforts over time.
Effective self-management strategies are provided to patients.
Suitable resources are provided to support patient self-management and health prevention.
A priori theme of ‘empowerment and support of patients for self-management and prevention’
Support delivery of comprehensive evidence-based care‘My healthcare worker has the resources, knowledge and support to provide me with comprehensive evidence-based chronic disease care’Healthcare teams are equipped with necessary supplies, medical equipment, laboratory access and essential medications.
Guidelines and diagnostic and treatment algorithms are implemented to support delivery of evidence-based chronic disease care.
Healthcare workers have access to specialist advice.
Support, education, training and retraining are delivered through programmes such as clinical mentoring to facilitate decentralisation of chronic disease care.
Training for healthcare workers is provided to help promote patient self-management and support behavioural change.
A priori theme of ‘equipped healthcare teams to deliver evidence-based patient-centred care’
New theme of ‘clinical mentoring’
Implement effective care, continuity and coordinationMy healthcare worker has access to my health information to advise me effectively and to plan and coordinate my ongoing care’.Useful patient data are collected, organised, stored securely and are accessible to guide patient care.
Continuity is delivered through planned and proactive follow-up to support evidence-based care for chronic diseases.
Reminder systems are in place for providers and patients.
Data are used to identify subpopulations for proactive care.
Data are used for individual care planning.
Clinical case management is implemented to meet the needs of complex patients.
Patient care is coordinated through effective communication and sharing of information between team members as well as between healthcare providers.
A priori theme of effective team-working to deliver continuity and coordinated proactive care
A priori theme of use of data collection systems to facilitate effective care and follow-up
New theme of ‘stigma and confidentiality’
Develop community partnerships‘My healthcare provider partners with my community to raise awareness, develop services, and increase support for chronic disease care’.Community awareness of chronic conditions is raised to reduce stigma.
Partnerships are formed with community leadership and organisations to support patient access to healthcare.
Local community resources are identified and mobilised to support screening, prevention and improved management of chronic conditions.
Complementary preventative and management services are provided where possible through mobilising an informal network of providers, such as community health workers and volunteers.
Patients are encouraged to take part in effective community programmes.
A priori theme of ‘community partnerships to promote awareness, mobilise resources and support health service provision’