We are working hard to improve Ongoing Care. This is based on the Integrated Chronic Disease Management programme in the National Department of Health. We have a a record kept by clinicians CCP Ongoing Care Record CLINICIAN 14-10-16, supplemented by a record of functionality CCP Review of functioning and ability. We also work with CHWs to follow up and provide them a plan/record for follow up CCP Ongoing Care Record CHW 14-10-16. This is kept in the CHW folder. As we manage the patient month-by-month we decide that if the patient is stable and not needing monthly visits to us that we can plan it accordingly using the Ongoing Care Records. We ensure the patient gets their medication safely and securely and is followed up regularly by CHWs with a CHW Delivery System using a CCP Chronic Script and a CCP Chronic Delivery form. The CHW record and copies of delivery are kept in the patients folder enabling clinicians to see them for any acute condition and check on their ongoing care. Patients are overjoyed!