Continuity of care aims at providing, enhancing and linking care across primary, secondary, tertiary levels for patients diagnosed with chronic diseases.

One of the main measures adopted by the Ministry of Health is the model of care. It was introduced as part of the new vision of our country (2030) in 2017. The model represents a method for restructuring health care through interactions between health systems and communities. It focuses on the patient's journey through health system and help to provide an organized, coordinated, and patient centered healthcare services. The outcomes of this model will be reflected on cost reduction, decrease in morbidity and mortality from chronic diseases as well as increase the satisfaction of patients and their caregiver.

We in the chronic care team are working together to improve chronic diseases care in the region that integrate the available resources with the best practices worldwide. We will also engage the healthcare workers at different healthcare levels to activate the role of multidisciplinary team in the management of chronic diseases.

• Screening for DM complication is conducted at the PHC level:

  Refer patient to 2nd or 3rd care if:

  • Uncontrolled patient with A1C > 9% and without successful treatment at the PHC for 1 years*¹.
  • Patients with comorbidities*².
  • Patients with complications.

  Refer patient to acute care centers if either:

  • One or more complications have been diagnosed*³.

  Criteria for Referral to Tertiary DM Center:

  • DM type 1.
  • DM1 for insulin pump.
  • DM1 for pancreatic or islet cell transplantation.
  • DM1 or 2 during pregnancy - GDM.
  • DM1 or 2 with CKD .
  • Steroid induced DM.
  • New onset DM post transplantation.

   

Continuing care services involve linking patients with community based services, home care services, primary care, secondary care, and tertiary care services, across different layers of care. 

Care Coordination Fundamentals Book by Primary Care Development Corporation.