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Implementing Chronic Disease Self-Management Support Model of Care

Chronic Disease Self-Management Support Model of Care  (1.9 MB)		Planning Where are you now?		Preparing Make it happen		Operationalise Make it stick
Governance		Identify chronic disease self-management support models Identify champions to lead the programs Process map the model Establish a steering committee		Develop a governance plan Consider the evaluation framework Develop key performance indicators See the SESIAHS Lessons Summary on Project Management		Monitor and evaluate against the KPIs Measure the impact of the self-management programs
Patient Journey How do patients flow through the hospital		Map the current patient journeys		Document successful patient stories including the perspectives of carers and/or family		Monitor patient / carer / family experience Make refinements and remap
Policies and Protocols		Identify current gaps in self-management support service provision Develop patient selection / referral criteria See the SESIAHS Lesson Summary - Change Management		Develop agreed pathways and protocols for: Referrals Assessment Problem definition / goal setting Action plan / care plan development Review / ongoing support Establish partnerships and agreements with other providers		Uses protocols Ensure ongoing review / refinement of policies and protocols based on feedback by all key stakeholders, including patients / carers / families Identify new protocols
People Understand who the staff are, how they function and what role they play in the patient journey		Identify target groups Engage key stakeholders Develop a staff profile Identify current providers, training and skill levels Identify current gaps in self-management support service provision		Develop competencies and position descriptions for self-management support staff Facilitate staff access to training		Develop a review process Regularly review and monitor staff workload and related arrangements
Resources		Conduct a resource survey to identify what is needed to establish selected self-management support models		Use existing staff capacity within teams Deliver required resources		Monitor resource use and modify as required
Communication		Develop communication plan See theSESIAHS Lesson Summary - Communications		Implement communications plan Identify how results will flow back		Regularly review the communications plan for effectiveness