Chronic Care Model/ Self-management /Patient centred care

Where is South African in its response to person-centred NCDs care?

 The national Department of Health is putting its money and credibility behind its Integrated Chronic Disease Management (ICDM) Model with little consultation. (Integrated Chronic Disease Management: A step by step manual to guide implementation. Undated. Authors Dr Shaidah Asmall and Dr Ozayrprinciples of person centred care Mahomed). This ICDM model is also cited as being integral to the NCD Strategic Plan.

The SA NCD Alliance is putting forward two key aspects that are import for patients, people living with NCDs. These are


•             SELF-MANAGEMENT (not assisted)

What is person-centred care?

A person-centred health system is one that supports people to make informed decisions about, and to successfully manage, their own health and care, able to make informed decisions and choose when to invite others to act on their behalf. This requires healthcare services to work in partnership to deliver care responsive to people’s individual abilities, preferences, lifestyles and goals.

The goal of person-centred care is to allow the patient to successfully manage their own health care – self-management. Self-management is one of the pillars for high quality care in the US Institute of Medicine’s definition.

Self management support is the job of the health care system it is fundamental and not an added extra. It is provided through graded active support.

There has be little or no consultation by the Department of Health with patients or patient group or caregivers about these matters. So we are putting up two references that back their importance.

Self management supportcan be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviours; and a fundamental transformation of the patient-caregiver relationship into a collaborative partnership.”

Bodenheimer T, MacGregor K, Shafiri C (2005). Helping Patients Manage Their Chronic Conditions. California: California Healthcare Foundation
Further information on self management support can be found at

The 2 resources listed below are very informative:

The Theory and evidence behind self management.  Slide presentation by Natalie Grazin, Assistant Director of The Health Foundation

A particularly important slide set that integrated the chronic care from the perspective of the patient – person living with an NCD.  It highlights how much change is necessary to implement such a model in current most chronic care settings.

Helping measure person-centred care A review of evidence about commonly used approaches and tools used to help measure person-centred care 2014 The Health Foundation: London by Dr Debra de Silva

This is an easy to ready snapshot of person-centred care with showing tools that can be used to measure different aspects of self-management.