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What are the Six Essential Elements of the Chronic Care Model?

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Today, chronic diseases account for over 46 percent of the global burden of disease, along with 59 percent of all deaths worldwide. Despite advances in treatments available for chronic conditions and improved effectiveness of these treatments, patients still may not get the care they need or want, resulting in poor overall health outcomes.  

The Chronic Care Model (CCM) exists to help medical practices change the routine delivery of care via six elements designed to make it easier to accomplish evidence-based, patient-centered care. Here’s a closer look at the Chronic Care Model along with the six essential elements included in the model designed to improve chronic disease management for patients.  

What is the Chronic Care Model?

improving chronic illness

Before diving into the elements of chronic care management models, what exactly is the Chronic Care Model? This model, created by the MacColl Center for Health Care Innovation in the 1990s, brought together information on strategies for managing chronic management, creating a more codified and easy-to-follow format.  

Later, the model was refined after input provided by a panel of experts, and then the model was tested nationally through the program “Improving Chronic Illness Care” in 1998. Later, in 2002, that program — along with a group of experts — further updated this model, offering more specific concepts for each of the six elements.  

Today, healthcare professionals have widely adopted this approach to improve ambulatory care, and it’s used to guide patient-centered medical home models and quality improvement initiatives at a national level.

The 6 Essential Elements of the Chronic Care Model

1. Health System/Organizational Support – Creating organizations that offer high-quality, safe care. The business plan of health systems must reflect their commitment to use CCM across the entire organization.  

  • Support improvements at every level 
  • Offer incentives based upon quality of care 
  • Encourage the systematic, open handling of quality issues and errors in order to improve care 
  • Create agreements supporting care coordination across organizations and within the organization 
  • Promote using improvement strategies designed to result in comprehensive system changes  

2. The Community – Community resources – including government, school, faith-based organizations, and non-profits — must be mobilized to meet patient needs.  

  • Create partnerships with these organizations to develop interventions and support to fill gaps in services for patients. 
  • Encourage patients to get involved in community programs 
  • Advocate for community policies that will boost patient care 

3. Self-Management Support – Prepare patients, and empower them, to better manage their own healthcare, encouraging them to monitor their conditions, identity challenges and barriers to care, and set goals.  

  • Stress the central role of the patient in healthcare management 
  • Help patients learn essential self-management support strategies, such as follow-up, goal setting, problem solving and action planning.  
  • Organization community and internal resources to offer self-management support to patients continually  

4. Delivery System Design – Ensure patients get efficient, effective care and self-management support. This may look like routine planned visits, helping patients maintain their best health while allowing practices to manage resources more effectively.  

  • Define team member roles and distribute care tasks among members of the team.  
  • Offer clinical case management services for patients with complex needs 
  • Have planned interactions that support evidence-based care 
  • Ensure patients understand care and receive care that best agrees with their unique cultural background 
  • Provide regular follow-up care  

5. Decision Support – Care provided must stay consistent with patient preferences and the latest scientific data surrounding each chronic condition.  

  • Ensure evidence-based guidelines get embedded into daily clinical practices 
  • Make use of proven provider methods of education 
  • Share evidence-based information and guidelines with patients to keep them involved in their care 
  • Integrate primary care and specialist expertise  

6. Clinical Information Systems – Ensure data stays organized to provide the most effective, efficient care. Harness technology to offer clinicians a registry of patients with a specific chronic disease, making it easier to reduce complications and continually monitor patient health status.  

  • Offer timely reminders for patients and providers 
  • Share information with providers and patients to better coordinate patient care 
  • Help facilitate patient care planning on an individual basis 
  • Monitor performance of the care system and practice team  

Key Takeaways

To successfully use the Chronic Care Model, it requires redesigning care within each of these six essential components. This may take rebuilding a whole new system that works along with your organization’s acute care processes as well. Change doesn’t happen overnight, but by testing these concepts and adapting them to your specific organization, healthcare organizations can better tackle chronic disease management, which has quickly become one of the biggest elements of primary care.  

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