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Table 3 Potential activities for inclusion in health centre’s action items, grouped under the six streams of the Chronic Care Model

From: Improving delivery of secondary prophylaxis for rheumatic heart disease in remote Indigenous communities: study protocol for a stepped-wedge randomised trial

Health system Delivery system design Decision support Clinical information systems Self-management Community linkages
Establish a multi-disciplinary RHD working group in health centres comprised of health centre staff and key stakeholders Allocate, confirm and document responsibility for ARF/RHD care among health centre staff to facilitate planned care interactions and follow-up Integrate evidence-based guidelines and decision support aids for ARF/RHD into daily clinical practice Monitor performance of practice team and care system in relation to ARF/RHD care using CQI processes Up-skill health centre staff in self-management support techniques through engagement with NT Department of Health training activities Partner with community resources to support timely delivery of SP to ARF/RHD clients
Support the NT Department of Health Steering Committee within NT Department of Health to coordinate RHD care Streamline care for ARF/RHD clients through:
o Fast-tracking at reception
o Process of client identification for opportunistic delivery of SP
o Prioritisation of case management for ARF/RHD clients with poor adherence
Ensure health centre staff are trained regularly on ARF/RHD care with an emphasis on SP planning and delivery Establish and refine systems to monitor and report ARF/RHD client data regularly to health centre staff to facilitate care planning Establish/strengthen group self-management support programme for ARF/RHD clients, facilitated by health centre staff where expertise available Strengthen health literacy activities in communities around RHD
Review and strengthen active systems of reminders and recalls for SP for health centre staff and ARF/RHD clients Explore sustainable incentives to ARF/RHD clients for adhering to SP Develop better understanding of community knowledge of and attitudes towards ARF/RHD care
  1. ARF acute rheumatic fever, CQI continuous quality improvement, NT Northern Territories, RHD rheumatic heart disease, SP secondary prophylaxis