A proactive approach that brings care professionals and providers together around the needs of service users to ensure that people receive integrated and person-focused care across various settings.
A structured multidisciplinary management plan (in addition to clinical guideline) that maps the route of care through the health system for individuals with specific clinical problems.
Individuals who provide care for a member or members of their family, friends or community. They may provide regular, occasional or routine care or be involved in organizing care delivered by others. Carers are in contrast with providers associated with a formal service delivery system, whether paid or on a volunteer basis (formal caregiver).
A targeted, community-based and proactive approach to care that involves case-finding, assessment, care planning and care coordination to integrate services around the needs of people with a high level of risk requiring complex care (often from multiple providers or locations), people who are vulnerable, or people who have complex social and health needs. The case manager coordinates patient care throughout the entire continuum of care.
A geographical area defined and served by a health programme, facility or institution, which is delineated based on population distribution, national geographical boundaries and transportation accessibility.
The processes through which actors are held accountable for continually improving the quality of their health services and safeguarding high standards of care.
Systematically developed, evidence-based recommendations that support health professionals and patients to make decisions about care in specific clinical circumstances.
The coordination of patient care across the system’s different functions, activities and operating units. The degree of coordination of care depends primarily on the patient’s condition and the decisions made by his or her health team. Clinical integration includes horizontal and vertical integration.
Health services that are delivered in an equal and reciprocal relationship between professionals, people using care services, their families and the communities to which they belong. Co-production implies a long-term relationship between people, providers and health systems whereby information, decision-making and service delivery become shared.
Coherence (of a national health policy, strategy or plan)
(a) The extent to which proposed strategies are aligned with the priorities identified in the situation analysis;
(b) the extent to which programme plans are aligned with the national health strategy and plan;
(c) the extent to which the different programmatic strategies in the national health policy, strategy or plan are coherent with each other; or
(d) the extent to which the budget, monitoring and evaluation framework and action plan introduce the proposed strategies.
A unit of population, defined by a shared characteristic (for example, geography, interest, belief, or social characteristic), that is the locus of basic political and social responsibility and in which every day social interactions involving all or most of the spectrum of life activities of the people within it takes place.
Person who provides health and medical care to members of their local community, often in partnership with health professionals; alternatively known as village health worker, community health aide or promoter, health educator, lay health adviser, expert patient, community volunteer or some other term.
The extent to which the spectrum of care and range of available resources responds to the full range of health needs of a given community. Comprehensive care encompasses health promotion and prevention interventions, as well as diagnosis and treatment or referral and palliation. It includes chronic or long-term home care and, in some models, social services.
The degree to which a series of discrete health care events is experienced by people as coherent and interconnected over time and consistent with their health needs and preferences.
The spectrum of personal and population health care needed throughout all stages of a condition, injury, or event throughout a lifetime, including health promotion, disease prevention, diagnosis, treatment, rehabilitation, and palliative care.
An approach suggesting that the health outcomes of individuals and the community depend on the interaction of multiple protective and risk factors throughout people’s lives. This approach provides a comprehensive vision of health and its determinants, which calls for the development of health services centred on the needs of its users at each stage of their lives.
