High performance team-based care for persons with chronic conditions

Area of Science:

• Healthcare Management
• Chronic Disease Management
• Public Health Policy

Background:

• Complex chronic conditions like diabetes necessitate coordinated healthcare teams and patient involvement.
• Israel has implemented structured diabetes follow-up through Clalit Health Services.
• National initiatives include quality indicators and health information exchange for care continuity.

Purpose of the Study:

• To evaluate the current state of diabetes care in Israel.
• To identify areas for improvement in managing complex chronic conditions.
• To emphasize the need for enhanced healthcare team development and patient partnerships.

Main Methods:

• Review of Clalit Health Services' structured diabetes follow-up protocols.
• Analysis of measures within the National Program for Quality Indicators in Community Healthcare.
• Assessment of health information exchange and hospital-community care continuity efforts.

Main Results:

• Israel has made progress in structured diabetes care and quality indicators.
• Initiatives for health information exchange and care continuity are underway.
• The need for purposeful development of healthcare teams is highlighted.

Conclusions:

• Coordinated, collaborative healthcare teams are essential for managing complex chronic conditions.
• Robust interprofessional education is crucial for future healthcare professionals.
• Strengthening partnerships between healthcare teams and patients is vital for optimal outcomes.