Background The Chronic Care Model (CCM) emerged in the 1990s as an approach to re-organize primary care and implement critical elements that enable it to proactively attend to patients with chronic conditions. A model with key elements of a health care system that encourage high-quality chronic disease care: the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Module 1 . This includes the Kaiser pyramid, the Chronic Care Model and the socio-ecological model. 5, 6, 7 To speed the transition, in 1998, Improving Chronic Illness Care created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels. Theory and models of care for chronic disease . effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. This approach creates patients who take an active part in their care. This section is about the theories that inform health system approaches to the prevention and management of chronic disease. The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. Basic concepts . The chronic care model is an organizational framework designed to improve the care for individuals with chronic conditions, one that incorporates the patient, the provider, and various system interventions. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. Other related models are being used to guide the provision of CNCD care within certain countries. 10 This seminal model … The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. The Chronic Care Model further elucidates the elements required to improve chronic illness care, including systems requirements for healthcare organization, community resources, self‐management support, delivery design, decision support, and clinical information. The Care Model. In 2002, WHO produced an expanded version of the model—the Innovative Care for Chronic Conditions (ICCC) Framework, which gives greater emphasis to community and policy aspects of improving health care for chronic disease. The chronic care landscape has evolved further, as most patients now present with multiple chronic conditions and increasing psychosocial complexity. Learning objectives The Chronic Care Model provides the best evidence-based framework for organizing and improving chronic care delivery to ensure productive interactions between an informed, activated patient and a proactive prepared practice team. The Chronic Care Model (CCM) is an effective framework for delivering planned, patient-centered care, with improved outcomes for individuals with chronic disease (Nutting et al., 2007). It encourages practical, supportive and evidenced-based chronic disease management using a proactive, rather than responsive approach. Evidence on the effectiveness of the Chronic Care Model was summarized in 2009. Chronic Disease . As shown in Figure 16.1, the Care Model depicts three overlapping spheres in which chronic care takes place: community, health systems, and provider organization (Bodenheimer, et al., 2002). The Chronic Care Model defines six domains that require attention in order to optimize outcomes: The Chronic Care Model is a method of caring for people with chronic disease in the primary care setting.
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