Alfrina Hany, S.Kp, M.

Ng (AC)
Informed, Productive Prepared
Activated Practice
Interactions Team
Patient

2
 What characterizes
a“prepared” practice
team?

Informed, Prepared
Activated Practice
Patient Team

They have the motivation, At the time of the

information, skills, and
confidence necessary to
effectively make decisions
about their health and
manage it.
interaction they have the
patient information,
decision support, and
resources necessary to
deliver high-quality care.

3
 How would I recognize a
productive interaction?

Informed, Productive Prepared

Activated Practice
Patient
Interactions Team

• Mengkaji kemampuan manajemen diri & kepercayaan diri

pasien berdasarkan status kesehatannya shg bisa menjadi self
manager yg baik
• Menyesuaikan manajemen perawatan dengan langkah -
langkah di SOP
• Active, follow-up secara berkelelanjutan. 4
Recognize Good Care for People
with Chronic Illness?
Informed,
Activated Patient
Supportive,
Integrated Prepared, Proactive
Productive Interactions Practice Team
Community

Functional and
Clinical Outcomes

• Assessment and tailoring

• Collaborative problem definition
• Evidence-based clinical management
• Goal-setting and problem-solving
• Shared care plan
• Active, sustained follow-up
• Community integration and support
• to maximize the quality of life for
chronically ill patients and to maximize
the quality and efficiency of their health
care.

The role of the Guided Care nurse is to work

in partnership with the primary care
physician, the patient, the patient’s
caregiver, members of the office staff, and
all other involved health care providers to
attain the goals of Guided Care.
1. Assessing the patient at home.
2. Developing evidence-based plans for managing the patient’s conditions
and summarizing them in a Care Guide and an Action Plan.
3. Monitoring the patient’s conditions and health-related behaviors
monthly.
4. Engaging the patient in self-management.
5. Coordinating the efforts of all the professionals who provide health care
to the patient.
6. Smoothing the patient’s transitions between sites of heath care,
especially in and out of hospitals, skilled nursing facilities, and
rehabilitation facilities.
7. Supporting the patient’s caregiver, who may be a relative or a friend.
8. Facilitating access to supportive services in the community.