Table 1.

Application of the Chronic Care Model to Intervention Design and Measurement

Chronic Care Model Domain	Intervention Component	Intervention Content	Measures
Health Care Organization	Nurse care management Patient registry Academic detailing Electronic tools	Create a standard of care across the organization	Baseline Survey:     - Learning Organization Survey (Garvin, Edmondson, & Gino, 2008)
Clinical information systems	Nurse care management Patient registry Academic detailing	Identify relevant sub populations (patients at highest risk for opioid misuse) for proactive care	Structured Observations:     -Interactions between nurse care manager (NCM) and patients     -Interactions between academic detailer and primary care physician (PCP)
	Nurse care management Patient registry Academic detailing	Plan individual patient care	Baseline Survey topics:     -Prescription Monitoring Program (PMP) registration     -PMP Utilization     -Making decisions for patient care using PMP data
	Nurse care management	Coordinate care by sharing information with patients and providers	Structured Observations:     -Interactions between NCM and patients     -Interactions between NCM and PCPs
	Academic detailing	Monitor performance of the practice team and the care system using audit and feedback	Baseline Survey:     - Learning Organization Survey (Garvin, et al., 2008)
Delivery system design	Nurse care management Patient registry	Define roles and distribute tasks among team members Support evidence-based care through use of planned interactions Provide clinical case management services for complex patients Provide regular follow-up by the care team Provide patient with culturally sensitive care	Structured Observations:     -Interactions between NCM and patients     -Interactions between NCM and PCPs Qualitative interviews:     -Interviews with PCPs regarding their experience of the intervention Baseline Survey:     -Learning Organization Survey (Garvin, et al., 2008)
Decision support	Nurse care management	Share evidence-based guidelines and information with patients to encourage participation	Structured Observations:     -Interactions between NCM and patients     -Interactions between NCM and PCPs
	Academic detailing Electronic tools	Use of proven provider education methods	Google Analytics:     - Statistics on utilization and traffic for the website
			Follow-Up Survey topics:     -Usefulness of the website and its content     -Suggestions for improvement
	Academic detailing	Integrate specialist expertise and primary care	Structured Observations:     - Interactions between academic detailer and (PCP)
Self-management support	Nurse care management	Emphasize the patient's central role in managing their own health Use effective self-management support strategies, such as assessment, goal setting, action planning, problem solving, and follow-up Organize internal and community resources to provide ongoing self-management support to patients, such as referral to addiction treatment, food pantries, physical therapy, and behavior health resources	Structured Observations:     - Interactions between NCM and patients
The community	Nurse care management	Encourage patient participation in and provide referral to effective community programs, such as Alcoholics Anonymous, support groups, exercise groups, and the YMCA	Structured Observations:     - Interactions between NCM and patients
	Nurse care management Academic detailing	Advocate for policies to improve patient care by contacting the Department of Health for delegation capability for PMP lookups and by working with local pharmacies to distribute naloxone rescue kits	Field Notes:     - Field notes on advocacy activities