Table 2 EMPOWER-PAR CDM Workshops’ Objectives, Contents and Teaching–Learning Methods

Workshop 1

• Organisation of health care (providing leadership and removing barriers to care)

At the end of this workshop, the participants should be able to:

1. Introduction to CDM and CCM

• Lecture

• Delivery system design (coordinating care processes)

• Discuss the concept and principles of CDM & the CCM

2. Redesigning delivery of care for chronic conditions

• Small group hands-on sessions

• Discuss the need to coordinate care for chronic conditions using multidisciplinary care team

3. Building a multidisciplinary CDM Team

• Group presentation

• Define roles and responsibilities of the team members

• Defining roles and responsibilities

• Formulate a plan on how to re-design the delivery of chronic care in your own practice setting

• Identifying barriers and resolving potential conflicts

• Formulate a plan on how to improve care coordination

• Improving care coordination

4. Delivery system re-design to improve care coordination

• Developing clinic-based registries

• Creating appointment system, reminder mechanisms and defaulter tracing

Workshop 2

• Self-management support (facilitating of skills-based learning and patient empowerment)

At the end of this workshop, the participants should be able to:

1. Introduction to self management support

• Lectures

• Discuss the concept and principles of self-management support

2. Patient-centred communication:

• Small group hands-on sessions

• Demonstrate patient-centred consultation to support patients’ self-management

• Building relationship and partnership

• Consultation practice of various clinical scenarios using simulated patients and the Global CV Risks Self-Management Booklet as a tool

• Guide patients to make informed decision

• Shared decision making

• Motivate patients to change their behaviour

3. Building Relationship

• Utilise the Global CV Risks Self-Management Booklet to empower patients

• Gathering clinical information & patient experience

• Exploring ideas, concerns and expectations

• Engaging patient

4. Sharing information and goal setting

• Providing sufficient information

• Explaining in simple language

• Assessing understanding

• Goal setting

5. Reaching agreement in management plan

• Involving patient in decision making process

• Reaching agreement

6. Motivating patients to change

• Motivating patients to change their lifestyle

• Achieving adherence to therapy

• Self-monitoring of blood pressure and blood glucose

• Supporting patients with self management tools

Workshop 3

• Decision support (providing guidance for implementing evidence-based care)

At the end of this workshop, the participants should be able to:

1. Introduction to evidence-based care and decision support

• Lectures

• Clinical information systems (tracking progress through reporting outcomes to patients and providers)

• Discuss the importance of evidence-based care

2. Implementing CPG

• Small group hands-on sessions

• Community resources and policies (sustaining care by using community-based resources)

• Identify potential solutions to improve CPG implementation in primary care clinics

• Identifying facilitators for change and possible solutions

• Utilize the T2DM and HPT CPG to aid management and prescribing.

• Using CPG in daily clinical practice

• Formulate a plan on how to improve the clinical information system (CIS)

3. Improving CIS and designing a clinical audit project

• Discuss the importance of Clinical Audit in improving quality of chronic disease management

• Identifying areas needing improvement

• Sampling frame and sample sizes

• Sampling methods

• Activity charts

• Design a Clinical Audit Project

• Criteria and standards

• Recommend remedial actions to improve chronic care quality

• Preparing data collection format

• Data analysis and interpretation of results

• Remedial action plan and

• Discuss the importance of community resources

• Implementation

• Group presentation

• Completion of the audit cycle

• Distributing tasks among team members

4. Community Resources

• Identifying available resources in your community

• Developing collaborative partnership with NGO’s and community leaders