Chronic disease management has become a key priority in Latvia as non-communicable diseases are characterized by relatively high preventable hospitalizations and poor care outcomes.
Objective of the study was to assess current situation and identify measures to improve chronic diseases management in primary care. A survey based the Patient-centered medical home assessment (PCMH-A) instrument was developed. Primary care specialists (N= 87) rated their current practice at 4 levels (D, C, B, A) with assigned rates from 0 to 3 in 5 areas: organization, patient centeredness, availability of services, coordination and medication. Each area was assessed on the basis of points obtained and expressed as a percentage of the sum of the maximum possible points. The study justifies rather low level of management of chronic patient care in GP practices: no element of care exceeds 50% of the highest performance expected. Organization of care is evaluated at the level of 36.85%, patient centeredness at 33.96%, availability and planning of services – 48.19%, care coordination - 45.19% and availability of medication - 38.72 % level. The study identifies measures for the improvement of care management: introduction of individual patient care plans and targeting chronic patients, complete approach to evidence-based clinical algorithms, monitoring of results and data collection and exchange between specialists. Chronic disease management in primary care requires improvements related to care coordination, systemic patient clinical monitoring, multidisciplinary approach and support for patient self-care. The development of individual patient care plans and the development of primary and secondary care teams are recommended as key elements of coordination. The role of GPs and all other stakeholders in the care of chronic patients needs to be defined, including social care and local government responsibilities, and an integration-oriented model of cooperation and support needs to be established.
- 3.4. Other publications in conference proceedings (including local)