Table 1.
Core Element | Focus |
---|---|
Healthcare Delivery System Redesign | Plan and manage to facilitate preventive care; redefine roles for the clinical team to implement CCM elements. |
Healthcare Organization Support | Organization-level leadership and resources for CCM (e.g., organization leadership to sustain CCM). |
Expert-Informed Decision Support | Provision of expert input to generalist clinicians to help manage cases without need for separate specialty treatment. |
Improving Clinical Information Systems | Track and coordinate care, facilitate information flow among clinical sources, the clinical team and patients. |
Fostering Patient Self- management | Coaching & problem solving to help patients self-manage disease and to participate in clinical decision making |
Linking Patients to Community | Enhance access to community resources (e.g., peer support groups, exercise programs, housing, home care programs). |
Source: Adapted from Bodenheimer, Wagner & Grumbach. Improving primary care for patients with chronic illness: the chronic care model, part 2. 2002.18