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The Chronic Care Model identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems. Within each of these elements, there are specific concepts (Change Concepts) that teams use to direct their improvement efforts. Change concepts are the principles by which care redesign processes are guided.
A health system’s business plan reflects its commitment to apply the CCM across the organization. Clinician leaders are visible, dedicated members of the team.
Community resources, from school to government, non-profits and faith-based organization, bolster health systems efforts to keep chronically ill patients supported, involved and active.
Patients are encouraged to set goals, identify barriers and challenges, and monitor their own conditions. A variety of tools and resources provide patients with visual reminders to manage their health.
Regular, proactive planned visits which incorporate patient goals help individuals maintain optimal health and allow health systems to better manage their resources. Visits often employ the skills of several team members.
Clinicians have convenient access to the latest evidence-based guidelines for care for each chronic condition. Continual educational outreach to clinicians reinforces utilization of these standards.
Health systems harness technology to provide clinicians with an inclusive list (registry) of patients with a given chronic disease. A registry provides the information necessary to monitor patient health status and reduce complications.
Successful system change means you will redesign care within each of the six components of the CCM; it does not mean tweaking around the edges of an acute care system not capable of handling the needs of the chronically ill. You will be building a new system that works in concert with your acute care processes. You will accomplish this by testing the above change concepts and adapting them to your local environment. The remaining steps in this manual help focus where you can start making these changes.
After learning more about the chronic care model, there are two things that may assist you in understanding how it directs system change:
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The MacColl Center's funding for Improving Chronic Illness Care ended in 2011, but our work to improve care with a patient-centered, team-based approach has continued. To access some of our more recent tools and resources, please visit these websites:
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