STFM CBC Chronic Care Model
Jeff Susman, MD
The chronic care model (CCM) is a product of Ed Wagner and the MacColl Institute for Healthcare Innovation, and reflects many years of development, application and assessment. There are six components to the CCM:
1. Organization of the health care delivery system
2. Community linkages
3. Patient self-management support
4. Decision support
5. Delivery system design
6. Clinical information systems
The Chronic Care Model Elements
Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.
Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.
|Delivery System Design
The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.
|Clinical Information System
A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.
|Organization of Health Care
Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.
To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.
Much of the underpinnings and application of the CCM overlap with the core concepts of performance improvement, the new model from the FFM, and other efforts to robustly describe the interactions among the patient, provider and practice, and community.
The CCM has been refined and the core concepts of the model have been applied to many common diseases including diabetes, asthma, congestive heart failure and depression. There is beginning to amass research that demonstrates at least short term improvements in outcomes with systematic application of the CCM (Shojania, JAMA 2006). Many of the CCM concepts can also be applied to preventive health services and even acute illness care. Thus, the CCM provides a robust model for enhancing the care of patients and populations.
The CCM has been the basis for a number of practice, academic (the ACCC) and now community improvement efforts (RWJ Aligning Forces for Quality). Recent informal evaluations (e.g., early Transformed findings, Ed Wagner comments) and more formal research provides the following insights:
- Changes in practice are difficult to make and sustain
- The current environment does not substantially value the CCM and many conflicting groups vie for providers attention
- Large organized systems such as the VA are better positioned to make the investment and develop systems to create a receptive environment for the CCM
- Strategic and leadership vision and support are important
- Champion(s) are important to CCM implementation
- Early adopters have been the first to embrace the model, but most health care professionals have not adopted this approach
- There need to be better alignment with financial and other incentives
- Integration between primary and specialty care, and different health care sectors is important
- Efforts to engage patients and consumers are in their infancy
Despite these challenges, the early evidence of successful implementation of the CCM in a variety of environments, suggests that this framework provides a productive and practical guide to performance and quality improvement.
The following instructional unit provides suggestions on learner competencies and approaches to teaching, learning and implementing the CCM.
Students by the end of their FM Clerkship
Be familiar with the chronic care model and describe its application to the management of chronic disease
Residents by graduation
Be able to apply components of the chronic care model within the residency practice to enhance care for chronic disease
Experienced Practicing Physicians
Lead the implementation of the chronic care model within a practice and effectively integrate chronic disease management into continuous performance improvement efforts
Link personal self assessment and maintenance of certification efforts with chronic disease management and performance improvement activities
Students by the end of their FM Clerkship will be able to:
Name the components of the Chronic Care Model
Understand the application of evidence based guidelines to the diagnosis and management of chronic disease
Describe the application of these components to a model chronic disease (e.g., asthma, diabetes)
Residents by graduation will be able to:
Understand the basic diagnostic and management issues with common chronic diseases including their etiology, risk factors, comorbidities, natural history, and treatment
Recognize the socioeconomic impact of the chronic disease on health care spending, overall health care delivery and the utilization of health care resources
Accurately assess their model practices’ activities relative to the chronic care model
Work with faculty to design and implement the chronic care model for improving the care of a common chronic condition
Begin to link personal knowledge (using the in-training exam), performance in practice (with quality measurement data from their practice), and performance improvement efforts using the chronic care model
Be comfortable using the electronic health record and disease management registries
Understand information from insurers and P4P efforts including common data flaws and problems
Experienced Practicing Physicians will be able to:
Effectively measure outcomes for chronic disease
Create and implement a chronic disease registry
Lead multidisciplinary office teams in ongoing improvement efforts to enhance the care of a target disease
Systematically assess efforts to enhance chronic disease management, including such problems as asthma, diabetes mellitus, congestive heart failure and depression
Link personal self assessment (from use of tools such as recertification exams and MOC activities) with practice assessment (using P4P data and other clinical outcomes data) to devise ongoing improvements in personal and practice improvement
Respond effectively to P4P efforts including appropriate appeal of inaccurate information
Effectively assess population health and use this data to target chronic conditions in a culturally astute manner
Extend the application of the CCM to preventive services and acute care
Students at the beginning of their FM Clerkship
Residents upon entry
Cultural competency and population health
Students at the end of their FM Clerkship
Residents upon graduation
Teaching and Learning Activities/Instructional Methods & Support Services/Needed Resources
Students during FM Clerkship
Lecture discussion describing the CCM elements
Paper on medical problem that incorporates evidence-based guideline
Project to enhance chronic or preventive care in practice
Practical experience with EHR, disease registry, elements of CCM on clerkships
Lecture discussion on CCM
Core didactics covering common chronic diseases that integrates EBM, population health, care managment
Use of EHR and disease residency in model practice
Development of PI project that incorporates elements of CCM including development and use of a disease registry, electronic flow sheets, planned/focused visits, patient empowerment strategies
Work with community agencies targeting chronic disease (e.g., AHA, ADA, ACS)
Facilitated practice assessment
Participation in AAFP METRIC or ABFM MOC activity
Participation in AAFP, IHI, or other practice improvement collaborative
Participation in IHI, AAFP or other focused conference on practice improvement
Work with QIO to enhance care of chronic disease
Implement disease registry or other element of CCM/new model of care
Respond to P4P data with planned PI intervention using CCM
Learner and Program Evaluation
Students by the end of their FM Clerkship
FM Shelf Exam
Percent who on a written or oral exam, when given a common chronic disease, can describe the application of the CCM in all of its components
Residents by graduation
FM In-training exam
Patient outcomes data including satisfaction
Within the model office setting, percent who can apply knowledge of the CCM to describe a project related to their own or teams’ population of patients
Percentage of residents who have had an opportunity to take part in a CCM project
Percentage of residents who actually complete CCM project and assess at least short term outcomes
Experienced Practicing Physicians
Clinical outcomes data including patient satisfaction, patient safety, efficiency, and other points on the quality compass
AQA, PQRI and other P4P data
Meet accreditation goals/standards
Continuity of care and development of enhanced medical home
Faculty Development and Lifelong Learning
PEP 3 module
Overview of the CCM
Application of the CCM to diabetes care
Institute for Healthcare Improvement
IOM description of application of CCM and health care reform
Department of Health Chronic Disease workshop
Links to the Academic Chronic Care Collaborative, California Academic Chronic Care Collaborative, Academic Rapid Response Collaborative and the AAMC Institute for Improving Care
IHI White Paper on planned care
Application of CCM concepts in CHCs
RWJ Improving Chronic Illness Care
RWJ Aligning Forces for Quality
Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF.Challenges of Change: A Qualitative Study of Chronic Care Model Implementation. Ann Fam Med. 2006 Jul; 4(4): 317-326.
Dietrich AJ, Oxman TE, Williams JW Jr, Kroenke K, Schulberg HC, Bruce M, Barry SL. Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression. Ann Fam Med. 2004 Jul; 2(4): 301-304.
Bodenheimer T. Innovations in primary care in the United States.
BMJ. 2003 Apr 12; 326(7393): 796-799.
Blue Ribbon Panel of the Society of General Internal Medicine.
Redesigning the Practice Model for General Internal Medicine. A Proposal for Coordinated Care: A Policy Monograph of the Society of General Internal Medicine. J Gen Intern Med. 2007 Mar; 22(3): 400-409. published online before print February 2, 2007
Planned visits to help patients self-manage chronic conditions.
Am Fam Physician. 2005 Oct 15;72(8):1454, 1456
Mohler PJ, Mohler NB. Improving chronic illness care: lessons learned in a private practice. Fam Pract Manage Nov/Dec 2005.