Future Thoughts: Transforming Healthcare One Idea at a Time

( Chronic) Care Model

While the (Chronic) Care Model (hereafter, CCM) is not “new” new (early 2000’s) it deserves more attention that it currently gets. The CCM initially started as a framework for implementing quality improvement in populations of patients with chronic health problems, but more recently it has been recognized that the model applies to all types of primary care problem.  As a result, sometimes the term “chronic” is deleted.  So don’t stop reading if you aren’t interested in “chronic” care!

The CCM  pre-dates the Patient Centered Medical Home, is widely used in CMS and other federal RFPs, and is an invaluable tool for analyzing and improving practice in terms of quality, process, efficiencies, and satisfaction.  My personal belief is that the CCM can be applied more broadly than the Patient Centered Medical Home, is less “medical”-centric and more user friendly.  The core components of the CCM are six discrete concepts that should be addressed when analyzing and improving primary care practices.  These concepts are organizational support, clinical information systems, delivery system design, decision support, self-management support, and community resources.  There is solid research evidence that improved practice in any of these areas results in improved patient outcomes.  And, although I have seen efforts to modify or “tweak” the model,  I think it is a pretty good the way it is and we should stop tweaking it and spend more time using the model.

The three infrastructure concepts are organization support, clinical information systems, and decision support tools. Organization support is the concept that a practice’s leadership provides the resources (time, money and people) needed to improve the practice.  A clinical information system is the data infrastructure essential to evaluate the practice; for example, data on patient outcomes and on practice processes.  Ideally a practice has an electronic health record, but having electronic data does not assure that data is readily available.  I have personally spent time auditing charts because the electronic health record does not report out essential data.  Decision support tools are things like the “pop-up reminders in charts and software apps such as Epocrates and Up-to-date; or, for those of you who are not tied to your smart phone, you can use the paper version…is anyone old enough to remember depending on the PDR for drug data?  That is one decision support tool I don’t want to go back to!

The other three concepts are more patient centered and include delivery system design, e.g. practice hours, group visits, and appointment scheduling, self management support strategies (a topic for another blog), and community resources.   The most complex of these three is community resources and the most underutilized area is self-management support strategies (see next blog).  Recently the community resources concept has been getting a lot more attention, especially as primary care providers begin to appreciate the impact of social determinants on health. Many primary care providers say that connecting patients with community resources is one of their greatest challenges.  The good news is that more and more practices are realizing the value of roles such as community health workers and nurse case managers to assist in connecting patients with community resources for everything from health education and peer support to food, clothing and shelter.

Although several other ideas have transformed primary care (the 1996 IOM report on Primary Care comes to mind),  I don’t believe the CCM has any competition for on-going potential in transforming primary care practice.  The model is simple to understand and utilize, applies to just about any primary care setting, and takes into account the provider, the patient, the data, the system, and the community.  I hope I have convinced you to learn more about the CCM if you are not already familiar with it.   For more information your best source is “improvingchroniccare.org”.  And don’t be “turned off” by the chronic care label; once you get into it, you can easily see how it applies to health promotion and acute care processes as well as chronic care.


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