摘要：Care for patients with complex chronic conditions such as diabetes requires a coordinated and collaborative team working in partnership with the patient. Israel has taken important steps forward with the development of structured diabetes follow-up by Clalit Health Services, including several measures of diabetes care in the National Program for Quality Indicators in Community Healthcare, and efforts to develop health information exchange and measures of continuity between hospital and community-based care. Achieving even better results will require purposeful development of health care teams to meet the needs of patients with single and multiple chronic conditions, including robust interprofessional education programs for the next generation of health professionals, and developing partnerships between the teams and the patients.
关键词：Health Care Team ; Exchange Health Information ; Multiple Chronic Condition ; Interprofessional Team ; Effective Partnership
