Chronic diseases and health promotion

Part Four - Taking action: essential steps for success

Chapter One: Providing a unifying framework - the role of government


Provide care across the continuum

Ideally, health-care settings (primary, hospital or community-based) should provide complementary services that collectively span the care continuum from prevention through to rehabilitation and palliative care.

Implementation step and suggested milestones
STEP 1 CORE: Pain medication is provided as needed as part of end of life care.

STEP 2 EXPANDED: Palliative services are provided to allow control of pain and other symptoms, and to permit death with dignity. Community-based rehabilitation programmes are established.

STEP 3 DESIRABLE: Multidisciplinary rehabilitation services are available.

Promote multidisciplinary teams
Multidisciplinary teams can consist of physicians, nurses, “expert patients” and others. Virtual teams – such as specialists linked to general practitioners by telephone – are increasingly common in rural or remote settings.

Implementation step and suggested milestones
STEP 1 CORE: Primary health care workers are trained by specialists on chronic disease management and on when to refer to specialty care.

STEP 2 EXPANDED: Remote links to specialists are established for rural health centres, and used for both consultation and back-referral.

STEP 3 DESIRABLE: Multidisciplinary primary health-care teams are organized, including, where possible, physicians, nurses, allied health professionals, and expert patients.

Ensure the health-care workforce has the right competencies
The health workforce is instrumental in stimulating, creating and maintaining improvements. Ministries of health should work with ministries of education and professional societies to ensure that the health workforce is taught the right skills to prepare them adequately for chronic disease prevention and management. Continuing professional education allows the health workforce to develop skills after completion of training. Educational activities include courses, on-site follow-up and coaching, and regular assessments and feedback on progress. Medical, nursing and other health professional societies are valuable partners in the provision of continuing medical education

Implementation step and suggested milestones
STEP 1 CORE: The health workforce, as part of its primary education, receives information and skills for chronic disease prevention and control.

STEP 2 EXPANDED: On-the-job educational opportunities are provided.

Step 3 Desirable: Continuing professional education on chronic disease prevention and management is mandated.

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