TABLE 1.

Theoretical elements of CLHSs, CLHS change concepts, and representations of change concepts in the preliminary model

Theoretical elements	CLHS change concept	Representation in preliminary model
Chronic Care Model	Implement all six aspects of the Chronic Care Model	Amount of data brought to clinical encounter, rules about how much information is produced, periodicity of encounters, implementation of treatment package
AOA ‐ Sufficient numbers of actors with the values and skills to self‐organize	Leadership to align all participants around a shared goal and to build a culture of generosity and collaboration	Rules for agent state changes (eg, becomes more active at x time‐steps, patient becomes less active if interacting with less active clinician). Rate of shared information brought to clinical encounter. Spread of activation via social network
AOA ‐ A commons where actors create and share resources	Platforms for creating and sharing common resources	Rate of information created that is shareable
		Rate of shareable information that is shared
AOA ‐ Processes, protocols and structures that make it easier to form functional teams	Network governance policies that facilitate sharing,	Information spread via clinician social network
AOA ‐ Processes, protocols and structures that make it easier to form functional teams	Quality Improvement as a common framework and method used by all for learning and improving	Rate at which information is implemented into treatment
AOA ‐ Processes, protocols and structures that make it easier to form functional teams	Data registries that support clinical care, improvement, and research	Amount of shareable data available

Note: Theoretical elements include the Chronic care model and the actor‐oriented architecture. CLHS change concepts have been shown to be common across existing CLHSs. ⁴ The representation of these in the preliminary model can be manipulated by stakeholders, and outcomes across different initial settings can be compared.