Table 4.
Core elements of Collaborative Chronic Care Model and related interventions
| Element | Focus | Potential practice components |
|---|---|---|
| Patient self- management support |
Practice able to provide coaching, problem-solving, skills-focused psychotherapy and psychoeducation to promote self-management and engagement in care |
Primary care provider training in use of common factors skills during routine visits; universal brief advice for parent-child interactions, stress reduction, problem solving; brief advice for specific clusters of symptoms |
| Clinical information systems use |
Facilitation of information flow from relevant clinical sources to treating clinicians |
Data systems for tracking progress and referrals |
| Delivery system re-design |
Re-definition of work roles of physicians and staff to facilitate anticipatory or preventive rather than reactive care |
All staff oriented and helped to develop common factors skills; scheduling to accommodate families with greater needs, team huddles to share information and anticipate family needs; integration of co-located services; consideration of processes for systematizing prevention and case-finding.. |
| Provider decision support |
Facilitated provision of expert- level input to generalists to reduce need for consultation separated in time and space from clinical needs |
Primary care staff training, development of collaborative and consulting linkages including warm lines, co-located services. |
| Community resource linkage |
Support for clinical and nonclinical needs from resources outside the health care organization |
Development of guides for referral to community services and family support programs |
| Health care organization support |
Organization leadership and tangible resources to support goals and practices |
Articulating the case for providing mental health care; developing markers for key goals |
Adapted from Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry 2012;169:790–804; with permission.