2.2.0.0 Chron­ic Care Model

Nu­mer­ous in­ter­ven­tions to im­prove ad­her­ence to the rec­om­mend­ed stan­dards have been im­ple­ment­ed. How­ev­er, a major bar­ri­er to op­ti­mal care is a de­liv­ery sys­tem that is often frag­ment­ed, lacks clin­i­cal in­for­ma­tion ca­pa­bi­li­ties, du­pli­cates ser­vices, and is poor­ly de­signed for the co­or­di­nat­ed de­liv­ery of chron­ic care. The Chron­ic Care Model (CCM) takes these fac­tors into con­sid­er­a­tion and is an ef­fec­tive frame­work for im­prov­ing the qual­i­ty of di­a­betes care (9).

Six Core El­e­ments. 

The CCM in­cludes six core el­e­ments to op­ti­mize the care of pa­tients with chron­ic dis­ease:

1. De­liv­ery sys­tem de­sign (mov­ing from a re­ac­tive to a proac­tive care de­liv­ery sys­tem where planned vis­its are co­or­di­nat­ed through a team-‍based ap­proach)
2. Self-‍man­age­ment sup­port
3. De­ci­sion sup­port (bas­ing care on ev­i­dence-‍based, ef­fec­tive care guide­lines)
4. Clin­i­cal in­for­ma­tion sys­tems (using reg­istries that can pro­vide pa­tient specific and pop­u­la­tion-‍based sup­port to the care team)
5. Com­mu­ni­ty re­sources and poli­cies (iden­ti­fy­ing or de­vel­op­ing re­sources to sup­port healthy lifestyles)
6. Health sys­tems (to cre­ate a qual­i­ty oriented cul­ture)

Redefining the roles of the health care de­liv­ery team and em­pow­er­ing pa­tient self-‍man­age­ment are fun­da­men­tal to the suc­cess­ful im­ple­men­ta­tion of the CCM (10). Col­lab­o­ra­tive, mul­ti­dis­ci­plinary teams are best suit­ed to pro­vide care for peo­ple with chron­ic con­di­tions such as di­a­betes and to fa­cil­i­tate pa­tients’ self-‍man­age­ment (11-13).