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 |