Table 1 Chronic Care Model elements and respective strategies
Model Elements | Approaches/Strategies |
|---|---|
Self-Management Support | - Emphasize the patient’s central role in managing their health - Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up - Organize internal and community resources to provide ongoing self-management support to patients |
Community | - Encourage patients to participate in effective community programs. - Form partnerships with community organizations to support and develop interventions that fill gaps in needed services. - Advocate for policies to improve patient care |
Health System | - Visibly support improvement at all levels of the organization, beginning with the senior leader. - Promote effective improvement strategies aimed at comprehensive system change. - Encourage open and systematic handling of errors and quality problems to improve care. - Provide incentives based on quality of care. - Develop agreements that facilitate care coordination within and across organizations |
Delivery System Design | - Define roles and distribute tasks among team members. - Use planned interactions to support evidence-based care. - Provide clinical case management services for complex patients. - Ensure regular follow-up by the care team. - Give care that patients understand and that fits with their cultural background |
Decision Support | - Embed evidence-based guidelines into daily clinical practice. - Share evidence-based guidelines and information with patients to encourage their participation. - Use proven provider education methods. - Integrate specialist expertise and primary care |
Clinical Information System | - Provide timely reminders for providers and patients. - Identify relevant subpopulations for proactive care. - Facilitate individual patient care planning. - Share information with patients and providers to coordinate care. - Monitor performance of practice team and care system. |