Around the world, every health care system is struggling with rising costs and uneven quality despite the hard work of well-intentioned, well-trained clinicians. Health care leaders and policy makers have tried countless incremental fixes—attacking fraud, reducing errors, enforcing practice guidelines, making patients better “consumers,” implementing electronic medical records—but none have had much impact.
“the definition of a long term condition is any condition that cannot be cured but can be managed by medication and/or therapy”. All long term conditions present a “common set of challenges” to individuals and their families between practice teams and patients that consistently provide (a) assessments, (b) support for self-management, (c) optimisation of therapy; and (d) proactive follow-up
Interventions based on Chronic Care Model components found reductions in health care utilisation or costs. The long term protocol involve patient in his care giving, define problems, set priorities, establish goals, create treatment plans and solve problems along the way. As guides to action, they may stimulate forward thinking and a focus on goals for patients and professionals. As a contract, they may include mechanisms to ensure actions are undertaken, for example by providing incentives to act. Examples include advance decisions within end of life care, which might be legally binding.