The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care

  1. For that initial message review and analyze the main concepts of the topic that you selected (chronic care) Besides the documents that were provided in the links of Module(below) (or Week 9 research the topic on your own to find at least one good reference (peer review article) and one reliable Internet site. The purpose of this first message is to think on ways you can apply some of these concepts and topics to the issues that you have identified as important to be solved in your country where you are a member of the MOH team(make sure that you attach the PDF of your peer-reviewed article that was taken from the library and the exact URL that links to your references (at least one) so others can review those source documents too;

Chronic Care videos

The Chronic Care Model webpage Ed Wagner (Links to an external site.)

Age Stickers aging  TV spot (Links to an external site.)

Model elements (Links to an external site.) 

Model Elements

The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.

The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.

Development of the Chronic Care Model

The staff at the MacColl Center for Health Care Innovation (Links to an external site.) at Group Health Research Institute developed the CCM in the mid-1990s by drawing on available literature about promising strategies for chronic illness management, and organizing that literature in a new more accessible way. The Model was further refined in 1997 during a nine-month planning project supported by The Robert Wood Johnson Foundation (Links to an external site.), and revised based on input from a large panel of national experts. It was then used to collect data and analyze innovative programs recommended by experts. RWJF funded the MacColl Center in 1998 to test the Model nationally across varied health care settings, creating the national program, “Improving Chronic Illness Care”.

Refinements to the Chronic Care Model

In 2003, ICIC and a small group of experts updated the CCM to reflect advances in the field of chronic care both from the research literature and from the scores of health care systems that implemented the Model in their improvement efforts. We list more specific concepts under each of the six elements. Based on more recent evidence, five additional themes were incorporated into the CCM:

  • Patient Safety (in Health System);
  • Cultural competency (in Delivery System Design);
  • Care coordination (in Health System and Clinical Information Systems)
  • Community policies (in Community Resources and Policies); and
  • Case management (in Delivery System Design).

The Model element pages describe the overall strategy for each element, and the health system change concepts necessary to achieve improvement in that component. The 2003 refinements have been identified in the related Model Elements page for reference. 

Please explore the current initiatives on Chronic Healthcare on the Robert Wood Johnson Foundation (Links to an external site.) Web-page.

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