The Chronic Care Model

1
The Chronic Care Model Overview

National Consultation, Central American Diabetes
Initiative (CAMDI) (Managua, Nicaragua, 23 July
2007)
2
Chronic Diseases

• Background
• Globally, 60 of all deaths are due to chronic
  diseases
• Majority of chronic disease deaths occur in low
  and middle income countries
• Threat is growing the number of people,
  families and communities afflicted is increasing

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Chronic Diseases

• Background (cont)
• Chronic disease has major adverse effects on
  quality of life
• In low-income countries, middle-aged adults are
  especially vulnerable to chronic disease
• Chronic disease hinders the economic development
  of many countries

4
Background

• The chronic disease threat can be overcome
• Common, modifiable risk factors underlie the
  major chronic diseases
• The science exists for optimal disease management
• The solutions are effective and highly
  cost-effective

5
What must be done?

• To evolve from acute focused find it and fix
  it health care systems towards ones that are
  proactive, provides comprehensive and coordinated
  care and are designed to meet the long term needs
  of patients.
• Trying harder will not work. Current health
  systems cannot do the job. Changing care
  systems will .
• US Institute of Medicine, 2001

6
Chronic Care Model

• The Chronic Care Model developed by the MacColl
  Institute for Healthcare Innovation (USA)
  provides a road map for redesigning the system to
  better manage chronic conditions
• This model can be applied to a variety of chronic
  illnesses, health care settings and target
  populations
• www.improvingchroniccare.org

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Chronic Care Model

• The model has been adopted by the WHO as the
  basis for its framework for managing chronic
  conditions
• Is used in many countries and health care
  organizations around the world
• Has been shown to improve patient outcomes and
  reduce costs for many chronic conditions
• www.who.int/chp

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Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
9
Chronic Care Model
HEALTH SYSTEM
Health Care Organizations
COMMUNITY
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
10
Six Focal Areas

• Health Care Organizations
• Visibly support improvement in chronic illness
  care at all levels of the organization
• Provide incentives to encourage better chronic
  illness care
• Facilitate care coordination throughout the
  organization

11
Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
12
Six Focal Areas

• Community Resources Policies
• Form partnerships with community organizations to
  support and develop interventions that fill gaps
  in needed services
• Encourage patients to participate in effective
  community programs
• Advocate for policies to promote health, prevent
  disease and improve patient care

13
Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
14
Six Focal Areas

• Self-Management Support
• Emphasize the patients central role in managing
  his/her health
• Use effective self-management support strategies
  that include goal setting, action planning and
  problem-solving
• Organize internal and community resources to
  provide ongoing self-management support to
  patients

15
Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
16
Six Focal Areas

• Decision Support
• Embed evidence-based guidelines into daily
  clinical practice
• Share evidence-based guidelines and information
  with patients to encourage their participation
• Integrate specialist expertise and primary care

17
Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
18
Six Focal Areas

• Delivery System Design
• Define roles and distribute tasks among team
  members
• Use planned interactions to support
  evidence-based care
• Ensure regular follow-up by the care team
• Give care that patients understand and that fits
  with their cultural background

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Chronic Care Model
HEALTH SYSTEM
COMMUNITY
Health Care Organizations
ClinicalInformationSystem
Self-Management Support
Resources Policies
Delivery System Design
Decision Support
Informed, Empowered Patient
Productive Interactions
Prepared, Proactive Practice Team
Improved Outcomes
20
Six Focal Areas

• Clinical Information Systems
• Provide timely reminders for providers and
  patients
• Identify subpopulations for proactive care
• Facilitate individual care planning
• Share information with patients and providers to
  coordinate care
• Monitor performance of practice team and care
  system

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Assessment of Chronic Illness Survey

• Tool to help organizations evaluate the strengths
  and weaknesses of their delivery of care for
  chronic illness
• Evaluates the organization of care rather than
  outcome, process or productivity measures
• Provides baseline information and guidance as to
  the system changes needed to improve care
• Survey questions focus on the six areas of system
  change identified by the Chronic Care Model as
  influencing quality of care

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Assessment of Chronic Care
Mean Rating (0-11)
Organization
Self-Management
Decision Support
Information Systems
Community Linkages
Delivery System Redesign
23
Questions