1. / 201 Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine Principles of Family Medicine Chronic Disease Management Dr. Zekeriya Aktürk zekeriya.akturk@gmail.com www.aile.net

2. / 202 30 % Top 10 cause of Death in KSA 1-Al Balla SR,. J Trop Med Hyg 1993;96:157-62 2-Bamgboye EA, Saudi Med J 1993;13(1):8-13.

3. / 203 Journal of Hypertension 2005, Vol 23 No 6 Hypertension

4. / 204 The overall prevalence of hypercholesterolemia TC > 200 mg/ dL: 35.4%. The overall prevalence of hypertriglyceridemia TG > 150 mg/ dL) : 49.6%. HDL Values in men and women Men <40mg/dL: 74.8 % Women <50mg/dL: 81.8 Al-Nozha MM.et al. Metabolic syndrome in Saudi Arabia. Saudi Med J 2005; 26 (12): 1918-1925 Dyslipidemia

5. / 205 Al-Nozha MM et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25 (11): 1603-1610 Diabetes

6. / 206 Obesity

7. / 207 Journal of Hypertension 2005, Vol 23 No 6 Smoking

8. / 208 Usual Care

9. / 209 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes

10. / 2010 Informed, Activated Patient Productive Interactions Prepared Practice Team Essential Element of Good Chronic Illness Care

11. / 2011 Informed, Activated Patient They have the motivation, information, skills, and confidence necessary to and confidence necessary to effectively make decisions about effectively make decisions about their health and manage it. their health and manage it. What characterizes an “informed, activated patient”?

12. / 2012 Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care. What characterizes a “prepared” practice team?

13. / 2013 Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. Organize resources to provide support. Self-Management Support

14. / 2014 Define roles and distribute tasks among team members. Use planned interactions to support evidence- based care. Provide clinical case management services for high risk patients. Ensure regular follow-up. Give care that patients understand and that fits their culture. Delivery System Design

15. / 2015 Regularly assess disease control, adherence, and self-management status. Either adjust treatment or communicate need to primary care immediately. Provide self-management support. Provide more intense follow-up. Provide navigation through the health care process. Features of Case Management

16. / 2016 Embed evidence-based guidelines into daily clinical practice. Integrate specialist expertise and primary care. Use proven provider education methods. Share guidelines and information with patients. Decision Support

17. / 2017 Provide reminders for providers and patients. Identify relevant patient subpopulations for proactive care. Facilitate individual patient care planning. Share information with providers and patients. Monitor performance of team and system. Clinical Information Systems

18. / 2018 Encourage patients to participate in effective programs. Form partnerships with community organizations to support or develop programs. Advocate for policies to improve care. Community Resources and Policies

19. / 2019 Visibly support improvement at all levels, starting with senior leaders. Promote effective improvement strategies aimed at comprehensive system change. Encourage open and systematic handling of problems. Provide incentives based on quality of care. Develop agreements for care coordination. Health Care Organization

20. / 2020 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes