Community oriented primary healthcare model
| Category | Disease prevention group | Chronic disease group I | Chronic disease group II | Bedridden group |
|---|---|---|---|---|
| Subjects | • Healthy without health risk factor •Has health risk factors but no disease |
•Well-managed chronic disease (including multiple chronic diseases) | •Uncontrolled chronic disease •Has complications •Has functional decline |
•Bedridden group •Terminally ill patients |
| Primary care services | ||||
| General health examination/regular examination | General health examination (annually or biennially) | General health examination or chronic disease management examination | General health examination or chronic disease management examination | – |
| Vaccination | Vaccination guidance and vaccination | Vaccination guidance and vaccination | Vaccination guidance and vaccination | Vaccination guidance and vaccination |
| Appropriate medical service | Ambulatory care (acute disease) | Ambulatory care (acute or chronic disease) | Ambulatory care (acute or chronic disease) | Home visit healthcare service |
| Comprehensive assessment and health management planning | Face-to-face consultation (within 1 month of registration) | Face-to-face consultation (within 1 month of registration) | Face-to-face consultation (within 1 month of registration) | Home visit consultation |
| Encouragement of healthy lifestyle practices | Text messaging, telephone consultation, face-to-face consultation | Text messaging, telephone consultation, face-to-face consultation | Text messaging, telephone consultation, face-to-face consultation | – |
| Health education (exercise, nutrition, alcohol, smoking cessation, weight management) | Telephone education, face-to-face education | Telephone education, face-to-face education | Telephone education, face-to-face education | Face-to-face education |
| Self-management of chronic disease (self blood pressure/blood sugar check, insulin injection technique) | – | Face-to-face consultation, remote information provision | Face-to-face consultation, remote information provision | Face-to-face consultation, remote information provision |
| Monitoring and counseling | – | Text messaging, telephone counseling, face-to-face counseling (once or twice a month) | Text messaging, telephone counseling, face-to-face counseling (once or twice a month) | Text messaging, telephone counseling, face-to-face counseling |
| Referral for medical counseling | If necessary | If necessary | If necessary | If necessary |
| Case management | – | – | Case management, home nursing, home rehabilitation, oral care | Case management, home nursing, home rehabilitation, oral care |
| Medication guidance, polypharmacy management | – | Medication guidance, polypharmacy management | Medication guidance, polypharmacy management | Medication guidance, polypharmacy Management |
| Community-centered activities and services | ||||
| Support for health-focused small group | Meeting information sharing, voluntary participation | Meeting information sharing, voluntary Participation | Meeting information sharing, voluntary participation | – |
| Volunteer activities | Voluntary participation | Voluntary participation | Voluntary participation | – |
| Group health education | Regularly or irregularly | Regularly or irregularly | Regularly or irregularly | – |
| Long-term care services | – | – | Day care center, home-based long-term care services | Home-based long-term care services |
| Community resource coordination | Government and local resource information provision | Government and local resource information provision | Government and local resource information provision, inter-agency service coordination | Government and local resource information provision, inter-agency service coordination |
–, not applicable.