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  <head>
    <title>071-03 Management, monitoring, prevention, safety, ethics, systems issues, and longitudinal care</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Longitudinal management in primary care">
      <outline text="Goals before disease targets">
        <outline text="Reduce harm without overwhelming the person">
          <outline text="Each addition needs purpose, review, stopping rule"/>
        </outline>
        <outline text="Start from what matters most to the person">
          <outline text="Translate values into measurable goals"/>
        </outline>
        <outline text="Shared decisions still include clear advice"/>
        <outline text="Relax targets when harm outweighs benefit">
          <outline text="Age alone does not exclude effective therapy"/>
        </outline>
        <outline text="One integrated plan with named owners">
          <outline text="Patient is not the only information conduit"/>
        </outline>
      </outline>
      <outline text="Polypharmacy as dynamic exposure">
        <outline text="Verify what is actually taken">
          <outline text="Ask how medicines are organised and missed"/>
        </outline>
        <outline text="Prescribing cascade">
          <outline text="Adverse effect treated as a new condition"/>
          <outline text="Time new symptoms against medication changes"/>
        </outline>
        <outline text="Deprescribing when harm exceeds benefit">
          <outline text="No indication, duplication, high-risk combinations"/>
          <outline text="Taper some, change few, monitor outcome"/>
        </outline>
        <outline text="Transitions are high risk">
          <outline text="Reconcile what stopped, started, changed"/>
          <outline text="Dosing aids do not solve intentional non-use"/>
        </outline>
      </outline>
      <outline text="Monitoring that answers questions">
        <outline text="Control, toxicity, adherence, progression"/>
        <outline text="Interval from kinetics, stability, actionability">
          <outline text="Too often detects noise, too rarely misses decline"/>
        </outline>
        <outline text="Condition reviews beyond refills"/>
        <outline text="Home monitoring: agency versus anxiety">
          <outline text="Validated devices and response pathway"/>
          <outline text="Wearables give false alarms"/>
        </outline>
      </outline>
      <outline text="Prevention by absolute benefit">
        <outline text="Life-course review of preventive care">
          <outline text="Bundle, but do not displace the concern"/>
        </outline>
        <outline text="Smoking cessation benefits at every age"/>
        <outline text="Weight counselling without stigma"/>
        <outline text="Specific physical activity prescriptions"/>
        <outline text="Screening weighs life expectancy, overdiagnosis">
          <outline text="Stopping must not imply life matters less"/>
        </outline>
      </outline>
      <outline text="Adherence by reducing friction">
        <outline text="Intentional, unintentional, structural">
          <outline text="Diagnose the barrier, not moral failure"/>
        </outline>
        <outline text="Simplify dosing, align refills, involve pharmacists"/>
        <outline text="Teach-back and motivational interviewing"/>
        <outline text="Written action plans for episodic conditions">
          <outline text="Baseline, warning signs, steps, when to seek help"/>
        </outline>
      </outline>
      <outline text="Referrals and transitions">
        <outline text="Referral states question, urgency, goals"/>
        <outline text="Referrer responsible until transfer accepted">
          <outline text="Bridging care and escalation criteria"/>
        </outline>
        <outline text="Reconcile advice with whole-person plan"/>
        <outline text="Early post-discharge period is high risk">
          <outline text="Early contact checks symptoms, medicines, support"/>
        </outline>
        <outline text="Multidisciplinary care needs explicit roles"/>
      </outline>
      <outline text="Digital care and access">
        <outline text="Telehealth cannot replace every examination">
          <outline text="Confirm identity, location, privacy"/>
        </outline>
        <outline text="Portals may exclude some patients">
          <outline text="Urgent symptoms not via asynchronous messages"/>
        </outline>
        <outline text="Automated summaries need verification"/>
        <outline text="Missed appointments are clinical information">
          <outline text="Proportionate outreach"/>
        </outline>
      </outline>
      <outline text="Relational ethics">
        <outline text="Warmth within professional limits"/>
        <outline text="Confidentiality in family and community"/>
        <outline text="Honest disclosure of errors and delays">
          <outline text="Second opinion or complaint without fear"/>
        </outline>
        <outline text="Carer involvement with consent">
          <outline text="Assess carer health separately"/>
        </outline>
        <outline text="Changed capacity: legal pathway, prior values"/>
      </outline>
      <outline text="Success through function and experience">
        <outline text="Outcomes beyond biomarkers">
          <outline text="Lower value is not success if patient falls"/>
        </outline>
        <outline text="Periodic whole-plan reviews">
          <outline text="Ask what could be stopped"/>
        </outline>
        <outline text="Anticipatory and advance care planning"/>
        <outline text="Cycle: prioritise, act, measure, simplify, revise"/>
      </outline>
    </outline>
  </body>
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