We assisted Det Nære Sundhedsvæsen in improving follow-up care for patients with chronic illnesses in regionally managed GP practices.

SITUATION​

Det Nære Sundhedsvæsen operates three GP practices in the southern part of Region Zealand. The quality of follow-up care for patients with chronic conditions is critical for their health and for reducing the overall strain on the healthcare system. Therefore, it was necessary to develop an effective method for assessing and monitoring the quality of annual check-ups.

RESULTS

Based on clinical guidelines, we developed a method and mapped the content of annual check-ups for patients with COPD, diabetes, and hypertension. This mapping provided an immediate overview of quality and the reasons for deviations, leading to several targeted efforts, such as increased use of care plans, updates to clinical guidelines, and systematic follow-up.

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DELIVERABLES

​As a basis for improvement efforts, we provided a mapping of the quality of care programmes and the follow-up care for chronic patients in local clinics, along with specific knowledge and recommendations for improvements, including concrete suggestions regarding planning, follow-up, and standardisation.

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