Table 1.

A priori codes identified from the CCM

CCM elements	Change concepts	Codes
Health systems Create a culture, organisation and mechanisms that promote safe, high-quality healthcare	Leadership motivated to make improvements and handle errors systematically	Organisational culture for safety and quality
Self-management support Empower and prepare patients to manage their health and healthcare	Self-management support strategies to enable goal setting, action planning and regular follow-up emphasising patients’ central role	Support for self-management
Delivery system design Assure effective, efficient clinical care and self-management support	Clearly define roles and distribution of tasks among the healthcare team for planned interactions	Planned interactions based on defined roles of team
Decision support Promote clinical care consistent with scientific evidence and patients’ preferences	Enable use of evidence-based guidelines through provider education	Guidelines and provider education
Clinical information systems for individual care plan Organise patient and population data to facilitate efficient and effective care	Provide timely reminders for follow-up and identify high-risk patients for appropriate action	Follow-up care
Community resources and policies Mobilise community resources to support patients	Form partnerships with community organisations to support and fill gaps in health service provision	Community linkages

CCM, chronic care model.