Care

provider Communicator Dicision maker Manager Community leader

Who considers the patient an individual and as integral part of family and the community, provide high quality, comprehensive, continuous and personalized care whitin long-term, trusting relationship

Who is able to promote helty lifestyles by effective explanation and advocacy, there by empowering individual and groups to enhace and protect their health.

Who makes scientifically sound jadments about investigation, treatments and use of technologies that make into account the patients wishes, ethical value, costeffectiveness consideration and the best possible care for the patient.

Who can work hamonisly with inviduals and organization both within and outside the health system to meet the need of individual patients and communities, making appropriate use of available health data.

Who having won the trust of the people among whom he or she works, and reconcile individual and community health requerments, advice cizen group, and initiate action on behalf of the community.

Doctor

Medical analisis

Ethical analisis

Medical indication

patient preferens quality of life others

Treatment

Caracteristics maine goel of care Duration Knowledge

Acut care cure

Chronic care control progression of the condition, incris survival enhance quality of life Long term, indifinite or life long. Health profesionals patient and family shere complementary Relevant multi drug & self managemen strategy with appropriate health system, community and family support. Comorditis are usually present Relevance of systemic quality upproach

Limetid Consentrated on health profesionals Focus on acute & single medical treatment

Disease management

Quality of care

Mosly contained approach within instituision

Their illnes is serious Their condisions essentially self-managed They have obtion They can change behaviour

Start at the problem Develop colaborative goel

Agree on the problem Negotiate resonable goel Generate obtions Decide on a mutually agreable and fesiable regim Get the significant others involved Screen for readiness

Educational Behavioural Affective

Identify the chronic disease and define the target population for disease management Organize a multy diciplinary team Define core components, treatment protocols, and evaluation methods Measure the outcomes and aim to continous quality improvement