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Table 1 Principles of DIVERT-CARE

From: Lessons learned implementing and managing the DIVERT-CARE trial: practice recommendations for a community-based chronic disease self-management model

  Principles Steps taken for Population-Based Care Approach
1. Multi-disciplinary teams at each site are trained on the protocols and resources related to each cardio-respiratory management model component. Baseline analytics were conducted to understand clients’ needs and preferences who were identified by the DIVERT scale score. This provided context for the resources and how they needed to be modified.
2. Teams identify steps required to deliver the intervention(s) Analytics were discussed at the operation level to understand the impact on intervention delivery. Regional implementation teams provided information on their health system and resources. In-person exercises were facilitated, and projections were conducted to identify human resource levels needed to deliver the intervention.
3. Deployment of the nurse-led cardio-respiratory management model that engages clients, families, and caregivers to ensure that adequate resources are dedicated to supporting the interventions across the intervention caseloads while ensuring long-term sustainability Supported by the national implementation team, regional implementation teams used identified steps and resources to deliver CDM. Ongoing virtual and in-person support occurred throughout the trial period to return to earlier steps to address challenges, provide training for additional personnel, and for ongoing enhancement of processes.