1. Multiprofessional health center Büsum
PD Dr. K. Götz & M. Jünemann, MD, MBA
Porto
Workshop „PORT health centers: shaping the future of primary and long-term care in Germany“

2. Where is Büsum? North of Germany on the north-sea coast
Inhabitants 4,904 (2016) and tourists over 160,000 per year
Distance to Hamburg  123 km

3. Aim of our project
Long-term assurance and strengthening of the healthcare location Büsum
Supporting healthcare staff for pleasant working condition
Investigation in community-based care

4. Project content
Implementation of case management supported by telemedicine applications
Development of multiprofessional care paths
Use of volunteers for comprehensive patient care

5. Health center in local sponsorship advantage: municipal institutions

6. Preparation for the project
Evaluation of structure and process of care organization
Evaluation of patient perspective of care
Evaluation of mobility and accessibility of the practice
Team development within the pracitce (workshop activities)
Regular exchange of the steering group

7. Work packages
1) Implementation of case management for chronic conditions 2) Use of telemedicine applications 3) Implementation of a training system 4) Support through volunteers 5) Extension of clinical pathways and of a inter-professional quality management system

8. Chronic Care-Model Health care for the future
nach Wagner et. al, 2001; German adaption by Gensichen, Knieps, Schlette 2006
Organization of health care
Community
CM: self-management support
Training concepts: strengthening of self-responsibility
(„Empowerment“)
Volunteers
Delivery system design
Inter-professional treatment pathways: task sharing within the practice team CM: regular monitoring
Decision support
Cooperation, clinical pathways, quality management:
Evidence based guidelines for physicians from different diciplines and patients
Clinical information system
TM: Patient register, recall service, individualized treatment plan, electronic patient record
Productive Interactions
Prepared, proactive practice team
Informed, activated patient
Health care for the future

9. Health center Büsum PATIENT Case Manager Hospital Nurse Physicians
Practice assistant
Exercise offering
Training program
Nutrition counseling
Volunteers
Physical therapist
Pharmacy
Physicians
Hospital
Health center Büsum

10. Realization of CCM

11. Our team for project realization