Learning Objectives
By the end of this section, you will be able to:
- Define the Chronic Care Model and its components
- Explain the role that clinical information systems play in the Chronic Care Model
- Identify overarching goals of the Chronic Care Model
Because chronic diseases are associated with such high morbidity and mortality rates, it is important to prevent them from developing when possible. As a result, there has been a recent shift of focus to preventive medical and nursing care as opposed to the treatment of illnesses after diagnosis (Healthy People 2030, n.d.). Coinciding with this new focus, the Chronic Care Model was developed to guide the prevention, management, and treatment of chronic disease.
The Chronic Care Model
The Chronic Care Model was developed as a guide for the reorganization of health care delivery to effectively care for patients with chronic conditions. It has been used by many health care organizations to redesign their structure to focus on proactive prevention as opposed to reactive treatment of disease. At its core, the model emphasizes the role that health care organizations play within the larger community. When a community’s health system is functioning effectively, proactive health care teams and informed patients have productive interactions that achieve the goals of everyone in the system.
Link to Learning
See Figure 1 in this article published in the Delaware Journal of Public Health for a graphic representation of the Chronic Care Model.
Health Care Organization
Organization of the health care system is the foundation of the Chronic Care Model. Without appropriate organization and structure, the health care system would be unable to provide effective care for chronic illness. This area of the model includes four components: self-management support, delivery system design, decision support, and clinical information systems.
Self-Management Support
Self-management support refers to the assistance that patients with chronic illness need day to day. Specifically, this includes supports such as the extension of education about the chronic disease and an individualized program to assist individuals to manage their chronic diseases. For example, patients with diabetes often have individualized programs to monitor their blood glucose levels over time. These programs usually involve recording their glucose levels so a care team can review them and make personalized recommendations about medications and other interventions. It is also important to support goal development and increase problem solving to manage chronic diseases with the assistance of health care staff (Agency for Healthcare Research and Quality, 2014). For example, for patients with hypertension, the provider or other health care staff may assist the patient in setting a mutually agreed-upon goal such as limiting sodium intake to 1,000 mg/d. The care team would then help the patient figure out strategies to use to achieve this goal, using problem solving to come up with solutions to accomplish the goal.
Delivery System Design
The delivery system design portion of the Chronic Care Model involves the design of the care provided. This area ensures that effective, efficient care is provide. Important aspects of this component of the model include the following:
- defining roles of various health care team members
- ensuring regular follow-up by the care team through a variety of methods, including telephone calls, home visits, and clinic appointments
- providing case management for complex patient cases
- using evidence-based care in practice
Decision Support
The decision support component of the Chronic Care Model refers to the implementation of evidence-based guidelines into practice (Accelerating Care Transformation [ACT Center], n.d.). This can be done both in the clinic and inpatient settings. Essentially, when a nurse or other provider is caring for a patient with a chronic disease, they should be able to quickly pull up a system or database of information, including best practice guidelines, that can assist them in the treatment and management of the condition. This is especially helpful to effectively care for the patient when providers are not as familiar with a condition or are unsure about how to manage it.
Clinical Information Systems
Clinical information systems serve multiple purposes to help providers understand the medical composite of a patient or an aggregate group, as well as understand and manage preventive care for individuals with chronic diseases. With the sophistication of electronic medical records, the benefits of these systems aid in guiding treatment, identifying problems, and gauging progress of a chronic disease. (ACT Center, n.d.). Other aspects of this part of the model include
- facilitating individual patient care planning
- monitoring the performance of the care team and patient outcomes
- providing clinicians an inclusive list of patients with a specific chronic disease from which they can monitor patient health status over time
- sharing information with patients and providers to allow for smooth transitions and better coordination of care
Community
Community is the other large, foundational component of the Chronic Care Model. The synergism of community and chronic conditions facilitates prevention strategies. Medical facilities in the community are not in solidarity; rather, they form alliances with schools, spiritual or faith-based organizations, businesses, state and local programs, and other interested and impacted parties in the community. The goal of the relationship with these organizations is to ensure that the community remains involved in the ongoing care of its individuals.
Overarching Goals of the Chronic Care Model
The Chronic Care Model aims to improve the quality of care provided to patients with chronic disease to ensure optimal patient outcomes. The foundational goal of the model is to transform health care delivery systems so they are better equipped to provide quality care. The main overarching goals of the model include
- enhancing patient self-management: empowering patients with knowledge, skills, and resources needed to make informed decisions, adhere to treatment plans, and engage in healthy lifestyle behaviors
- fostering patient-centered care: promoting shared decision-making, patient education, and support for patients’ psychosocial and emotional needs
- improving patient outcomes: reducing complications, improving symptom management, enhancing quality of life, and optimizing functional status
- improving population health: addressing social determinants of health, promoting healthy behaviors, and implementing population-level interventions
- increasing health care access: ensuring appropriate access to primary care, preventive services, medications, and community support programs
- optimizing use of health care resources: reducing unnecessary hospitalizations and emergency department visits.
- promoting care coordination: communication, collaboration, and information sharing among health care team members.