Table 1 Components of the Chronic Care Model for health systems
Definition and examples of CCM components |
|---|
Decision support |
Embedding evidence-based guidelines into daily clinical practice (e.g., systems prompts and reminders; clinical pocket guides) |
Delivery system design |
Defining staff roles and distributing tasks appropriately among health team members to deliver coordinated care (e.g. use of non-physician staff to deliver counseling and coordinate care; clearly defined provider roles and responsibilities) |
Clinical information systems |
Utilizing patient and population data to facilitate efficient care, tracking and follow up (e.g., electronic medical records; patient registries; patient status summaries) |
Patient self-management |
Empowering patients to manage their own health through education and self-management support strategies (e.g., tailored educational resources; psychosocial support) |