Chris Ham talks to Edward Wagner, Director Emeritus, MacColl Center for Health Care Innovation, Group Health Research Institute, about co-ordinated care and the chronic care model.
Dr Wagner explains how his clinical work helped him to develop the chronic care model, encouraging the medical workforce to collaborate with patients to help them to manage and choose their own care.
He discusses who needs to be in a successful care team, how important a named caregiver is, and how the co-ordinated care model can be used to deliver more appropriate care for older people.
Need to be skilled up to play equal commissioning, service redesign role.
Health literacy should be gained in collaboration with patient, not didactic instructions.
Proactive Prepared Team should include GP, but probably not as leader, someone to support self-care, someone to support logistics eg transport.
Hunt's 'accountable clinician' should be a generalist with whole-person knowledge of patient who coordinates care - by previous comment, this precludes GP!
Integration relates to organisations - prioritise coordinated care: the deliberate activity of a team to protect patient from pitfalls of having to get care from different organisations