The protocol of chronic patient management in a family medicine practice

Abstract

Health care of patients with chronic diseases is a major challenge faced by health care systems worldwide. Primary care can offer good quality care for a range of chronic diseases, at the same time providing continuity of care and management of comorbidity. In Slovenia, the primary care faces a dilemma of how to provide the recommended acute, chronic and preventive care, considering the shortage of primary care physicians. New models of primary care teams are thus necessary for redesigning health care delivery systems to improve the care for patients with chronic conditions. In 2011, new model practices were implemented in our county. In these practices, a part of preventive and chronic care services are delegated to the new members of family physicians’ teams – specially trained nurses who deliver care according to newly introduced protocols for the management of chronic diseases. The protocols provide guidelines for primary health care teams in terms of clinical care and organisational aspects of practice. Much emphasis is also given to self-management support for patients, which is essential for extending health care outside the doctor’s office into patient’s daily life.