Table 4.

Additional themes included in existing CCM

Themes	Description
Patient Safety (in Health System	A system seeking to improve chronic illness care must be motivated and prepared for change throughout the organization. There is a need to identify care improvement and translate it into clear improvement goals and policies through application of effective improvement strategies, including use of incentives that comprehensive system change. Breakdowns in communication and care coordination can be prevented through agreements that facilitate communication and data-sharing as patients navigate across settings and providers.
Cultural competency (in Delivery System Design)	Improving health of people with chronic illness requires transformation of a system to one that is proactive instead of reactive. Roles need to be defined and tasks need to be distributed among team members. Interactions need to be planned to support evidence-based care. More complex patients may need more intensive management for a period of time to optimize clinic care and self-management. Health literacy and cultural sensitivity are two important features and providers are increasingly being called upon to respond effectively to the diverse cultural and linguistic needs of patients (Wielawski, 2011).
Care coordination (in Health System and Clinical Information Systems)	Effective chronic illness care is impossible without information systems that assure ready access to key data on individual patients as well as populations of patients (Wielawski, 2011; Wagner et al. 2002). An information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts.
Community policies (in Community Resources and Policies)	Mobilize community resources to meet needs of patients by advocating for policies to improve patient care.
Case management (in Delivery System Design)	Provide clinical case management services for complex patients and care that patients understand and that fits with their cultural background.