This approach creates patients who take an active part in their care. Involving patients in exploratory focus groups to inform the development of assistive technologies can customize educational technology and address usability concerns among unique patient populations (35). Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. Provided access to electronic shared medical record for patients and providers; included secured e-mail for interactive feedback with case managers. The Chronic Care Model identifies six fundamental areas that form a system that encourages high-quality chronic disease management. Coca A, Francis MD. Physicians and their patients were randomized to the control or intervention group (clustered randomization). The PCP and patient reviewed the message and decided how to proceed. The system also generates population reports so that physicians can view the progress of their patients with diabetes. Multilevel, cluster-design, randomized controlled trial (n = 104). CCM intervention group that received virtual consultation: median duration of diabetes, 4 y (range, 0–43 y); median age, 62 y (range, 22–92 y); median BMI, 33 (range, 18–66); median HbA1c, 7.3 (range, 5.2–15.1). Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Endocrinologists provided the telemedicine intervention, delivering these tailored messages to the primary care team for review 48 hours before the patient’s next scheduled visit. The 16 studies (9–24) (Table 1) included 9 randomized controlled trials (9–17), 2 prospective cohort studies (18,19), 3 natural experiments (20–22), 1 qualitative study (23), and 1 cross-sectional study (24). [email protected]. The Chronic Care Model (CCM) was developed in the USA after an extensive review of the literature and is the most widely known model of care for people with chronic conditions [10]. Registry was used to identify patients who had not been seen in 6 months or had HbA1c levels >8%. Interactive feedback using the Web-based My Diabetes Daily Diary self-management tool focused on nutrition, medications, and exercise. Patient registry was a major advancement for identifying patients, generating individual and private reports, and developing Plan-Do-Study-Act (PDSA) cycles for diabetes care. All rights reserved. ATSM seems to be a more effective communication method for self-management support than monthly GMV for improving behavior and quality of life for patients with poorly controlled diabetes. These systems helped patients and providers set self-management goals and review progress reports to determine whether patients met their predetermined goals (9,11,12,14,16–18,20,21,23,24). Baseline chart audit was conducted to establish benchmark for adherence to ADA standards of care and enhance provider feedback. Walk-in urgent care clinic for uninsured patients. Developed protocol to provide clinicians with key clinical information for each patient visit. Offered chronic disease self-management classes to teach patients behavioral goal setting and strategies to overcome barriers and promote peer support. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. Diabetes Public Health Resource; 2012. http://www.cdc.gov/diabetes/consumer/groups.htm. Stellefson ML, Hanik BW, Chaney BH, Chaney JD. Only 7 studies described strategies for addressing community resources and policies. The current model for most health-care delivery emphasizes acute care, dealing with individual problems as they arise (such as when a person goes to the doctor for a cold or the flu). All members of chronic care team must be able to access the care plan in a timely manner 9. No significant changes in HbA1c were found in ATSM, GMV, and usual-care groups. The Chronic Care Model focuses on practice improvement for patient-centered evidence-based proactive care of chronically ill populations. Study settings included academic-affiliated primary care practices (10,12–14,21,23), private practices (11,16,17,20), community health centers (15,24), safety net clinics (18,19,22), and a hospital (9). Nurses interacted most with the patients, using evidence-based algorithms from the Institute for Clinical System Integration to provide patient care and manage medications. Med Care Res Rev 2007;64(5 Suppl):101S–56S. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The model represents a method for restructuring health care through interactions between health systems and communities [ 5 ]. critiqued the data to identify any inconsistencies between data presented in the studies and the data extracted for the review, posed questions for further clarification on all extracted content, and then reviewed and synthesized the extracted data for accurate presentation within the context of the CCM. Clinic space was modified to provide services. Abbreviations: SD, standard deviation; ADA, American Diabetes Association; HbA1c, hemoglobin A1c; DSME, diabetes self-management education; CDE, certified diabetes educator; HDL, high-density lipoprotein; PCPs, primary care providers; BMI, body mass index; LDL, low-density lipoprotein; CI, confidence interval. It encourages practical, supportive and evidenced-based chronic disease management using a proactive, rather than responsive approach. “Lifestyle school” session included a model grocery store so participants could practice reading food labels, learn and apply skills to choose more healthful options during grocery shopping and when considering fast food options. Suggested citation for this article: Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. Tsai AC, Morton SC, Mangione CM, Keeler EB. Manag Care Q 1999;7(3):56–66. HbA1c, non-HDL cholesterol, and blood pressure levels at 3-year follow-up. CDE worked with staff to schedule DSME; CDE served as a clinical resource; PCPs hosted “diabetes days”; PCPs made direct referrals to CDEs. Finally, community-level partnerships pooled human and fiscal resources to provide diabetes management services (11,12,16–18,20,24). 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). Results The sum of these CCM component parts are purported to create more effective health care delivery systems that institute mechanisms for decision support, link health care systems to community resources and policies, deliver comprehensive self-management support services for patients, and operate and manage patient-centered clinical information systems. Used electronic medical records and flow sheets, which were valuable for contacting patients who have not been seen in a while, and in following the performance and progress of patients (eg, results for HbA1c, low-density lipoprotein cholesterol, blood pressure, foot examinations). Comprehensive electronic database consisted of data on patient interviews, examination and laboratory results, habits, attitudes, goals, medication use, and follow-up visit plans. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers who have the necessary resources and expertise. Chronic Care Model 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. Two studies (19,20) revised the health care system to redefine health care team roles (eg, nurses, instead of PCPs, became responsible for conducting foot examinations). How do I view different file formats (PDF, DOC, PPT, MPEG) on this site? Caruso LB, Clough-Gorr KM, Silliman RA. Accessed June 12, 2012. Problem-based learning sessions were held for PCPs, led by an endocrinologist using diabetes management questions. Used ADA diabetes education content areas. Blood pressure; HbA1c levels; documentation and follow-up of goal setting; eye and foot examinations; medical residents receiving/reviewing/discussing registry reports; medical residents learning and demonstrating self-management support strategies. Project was fully supported by the governing board of the Salvation Army Free Clinic. Patients led the discussion according to individual needs, and the CDE facilitated the discussion to include ADA’s 10 content areas. Future DSME for primary care patients should continue to cover the ADA content areas (28) for diabetes self-management, and strategies for delivering DSME should be evaluated by assessing the comparative effectiveness of group- and individual-level DSME approaches. Percentage of patients achieving goals for HbA1c, blood pressure, and LDL cholesterol. The ICCC has a larger focus on supporting “positive policy environments” (ie, partnerships, legislative frameworks, human resource allocation, leadership, and financing) in community and health care organizations (33,37). Future studies should examine the effects of continuing education for ADA Standards of Care and ICSI clinical guidelines on CCM decision support among providers. We excluded studies that took place outside of the United States, reported secondary data, or represented an editorial, commentary, or a literature review. Sustained outcomes in quality of well-being, self-monitoring of blood glucose. A low-cost decision support and information system based on the CCM is feasible in primary care practices, especially practices that lack sophisticated electronic information systems. CCM is used as the framework; laboratories provide daily data feeds; algorithms provide automatic test interpretation; fax and mail are used for providers not easily reached by electronic networks; reports are formatted for accessibility and usability by patients and providers. Liebman J, Heffernan D, Sarvela P. Establishing diabetes self-management in a community health center serving low-income Latinos. The same author (K.D.) Lyles CR, Harris LT, Le T, Flowers J, Tufano J, Britt D, et al. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Patients reported comfort with location and ease of approaching CDEs. Systematic reviews: CRD’s guidance for undertaking reviews in health care. Provided tracking forms and education materials. For older populations of chronic disease patients (the age group sampled in most of the reviewed studies), training programs on the use of digital technologies for diabetes self-management may reduce the anxiety and barriers to access that may currently exist (23,34).
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