Table 2.
Sample Interventions across Several Chronic Care Model Elements
| SELF-MANAGEMENT SUPPORT | |
|---|---|
| Diabetes Teams | CHF Teams |
| • Created self-management tool kit which included tracking forms, posters, calendars, etc. | • Collaborative goals set with patients for weight, medications, diet, blood pressure, etc. |
| • Held peer support groups • Televised self-management course to six counties | • Distributed logs and calendars for self-monitoring, e.g., salt intake • Provided scales to patients in need |
| • Linked individual patient goal-setting to the registry | • Developed scripts to teach patients how to raise issues with their physicians |
| Delivery System Re-Design | |
| Diabetes Teams | CHF Teams |
| • Implemented planned visits, group visits and/or chronic disease visits | • Routine telephone follow-up with patients • Added family practice MD to team for continual PCP input |
| • Posted notices in exam rooms for patients with diabetes to remove their shoes | • Prospective identification of CHF patients with appointment “today” |
| • Used registry reports & pop-up reminders for follow-up and care planning | |
| Decision Support | |
| Diabetes Teams | CHF Teams |
| • Posted guidelines on the Internet | • Formal medication “pre-fill” protocol developed |
| • Generated feedback for clinical teams on guideline compliance using registry data | • Cardiologists offer educational classes to PCPs to relate guidelines |
| • Requested electronic chart review & feedback from endocrinologist | • Integrated CHF protocols into routine practice |
| • Held routine meetings with social workers to discuss more challenging patients | • Evaluated best practices approach for treating CHF patients across medical community |