A Model that Benefits the Chronic Patients

Chronic Care Model

Model Elements

The Chronic Care Model (CCM) recognizes the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change theories under each element, in turn, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.

The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.

Dr Wagner developed the chronic care model and his collaborates helped in the development as well as the refinement of the model. Further information can be found in this link I have provided: http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18

Promoting effective change in provider groups to support evidence-based clinical and quality improvement across a wide variety of health care settings.

From many surveillance data collected over the past years, we can see that many chronic diseases has emerged in the population and Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others.

Those deficiencies include:

• Rushed practitioners not following established practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illnesses

To overcome the deficiencies, it will require the transformation of health care, from a system that is essentially reactive, responding mainly when an individual is sick, to one that is proactive and focused on keeping an individual as healthy as possible. Thus, to accelerate the transition, Improving Chronic Illness Care (ICIC) created the Chronic Care Model (CCM), which summarizes the fundamental elements for improving care in health systems at the community, organization, practice and patient levels.

The CCM consists of two main components, which is the health system and the community. Each of the components contains a few of the fundamental elements.

The model suggests that the patient-provider interactions resulting in care that improves outcomes are found in health systems that:

· have well-developed processes and incentives for making changes in the care delivery system

· assure behaviourally sophisticated self-management support that gives priority to increasing patients' confidence and skills so that they can be the ultimate manager of their illness.

· reorganize team function and practice systems (e.g., appointments and follow-up) to meet the needs of chronically ill patients

· develop and implement evidence-based guidelines and support those guidelines through provider education, reminders, and increased interaction between generalists and specialists

· enhance information systems to facilitate the development of disease registries, tracking systems, and reminders and to give feedback on performance.

Health system

Delivery System Design

Assure the delivery of effective, efficient clinical care and self-management support

• 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

Clinical Information Systems

Organize patient and population data to facilitate efficient and effective care

• 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

Decision Support

Promote clinical care that is consistent with scientific evidence and patient preferences

• 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

Community

Resources and Policies

Mobilize community resources to meet needs of patients

• 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

Self-Management Support

Empower and prepare patients to manage their health and health care

• 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

By focusing on the improvement of those 5 elements, the individuals whom are suffering from chronic diseases will be treated, managed, and received the medical attention needed in order for them to live life productively without complications and deterioration of their disease condition.

References:

http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.htm

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2