Full Report

DISCUSSIONS &
RECOMENDATIONS
Summary of Recommendations
Table 4
Summary of Recommendations
Key Element (ECCM) Recommendation Rationale Necessary conditions
Self-management
Support (SMS)
SMS should become standard
practice for all primary care staff
in the NWT.
• Effective capacity building
tool for clinicians
• Creates more meaningful
relationships between
patients and providers
• Focuses on prevention
and management rather
than acute care
• Standard approach
and guidelines
• Contextualized and
tailored training
• Standard orientation
and re-training
• Strategies to facilitate patient
and provider engagement
• Sustainable resourcing to
support scale and spread
• Appropriate monitoring
and evaluation
Coordination
(as a component
of Health System
Design)
Adopt standardized policies and
pathways for clinical referral and
information sharing.
• Increases appropriate patient
flow and referral
• Increases communication
between providers creating
opportunities for more
interdisciplinary care
• Effective training and
orientation processes
• Standardized training
and orientation
• Sustainable resourcing to
support scale and spread
• Appropriate monitoring
and evaluation
• Strategies and opportunities to
facilitate more interdisciplinary
case management
Support the use of integrated
case management practices for
complex patients.
• Supports prevention
and management
• Creates opportunities for
increased communication and
interdisciplinary care
• Sustainable resourcing to
support scale and spread
• Provision of care teams
• Appropriate monitoring
and evaluation
• Align with other initiatives that
support the uptake of case
management
19
Making the Case for Change