1. The Chronic Care Model Overview
National Consultation, Central American Diabetes Initiative (CAMDI)
(Managua, Nicaragua, 2–3 July 2007)

2. Chronic Diseases Background
Globally, 60% of all deaths are due to chronic diseases
Majority of chronic disease deaths occur in low and middle income countries
Threat is growing – the number of people, families and communities afflicted is increasing
Globally, 60% of all deaths are due to chronic diseases
Majority of chronic disease deaths occur in low and middle income countries and these deaths occur in equal numbers among men and women
The threat is growing – the number of people, families and communities afflicted is increasing

3. Chronic Diseases Background (cont)
Chronic disease has major adverse effects on quality of life
In low-income countries, middle-aged adults are especially vulnerable to chronic disease
Chronic disease hinders the economic development of many countries
Chronic disease has major adverse effects on the quality of life of affected individuals.
In low-income countries, middle-aged adults are especially vulnerable to chronic disease.
Chronic disease results in millions of premature deaths thereby hindering the economic development of many countries

4. Background The chronic disease threat can be overcome:
Common, modifiable risk factors underlie the major chronic diseases
The science exists for optimal disease management
The solutions are effective – and highly cost-effective

5. What must be done?
To evolve from acute focused ‘find it and fix it’ health care systems towards ones that are proactive, provides comprehensive and coordinated care and are designed to meet the long term needs of patients.
‘ Trying harder will not work. Current health systems cannot do the job. Changing care systems will ’.
US Institute of Medicine, 2001

6. Chronic Care Model
The Chronic Care Model developed by the MacColl Institute for Healthcare Innovation (USA) provides a road map for redesigning the system to better manage chronic conditions
This model can be applied to a variety of chronic illnesses, health care settings and target populations

7. Chronic Care Model
The model has been adopted by the WHO as the basis for its framework for managing chronic conditions
Is used in many countries and health care organizations around the world
Has been shown to improve patient outcomes and reduce costs for many chronic conditions

8. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

9. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
Health Care Organizations
COMMUNITY
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

10. Six Focal Areas Health Care Organizations
Visibly support improvement in chronic illness care at all levels of the organization
Provide incentives to encourage better chronic illness care
Facilitate care coordination throughout the organization

11. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

12. Six Focal Areas Community Resources & Policies
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
Encourage patients to participate in effective community programs
Advocate for policies to promote health, prevent disease and improve patient care

13. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

14. Six Focal Areas Self-Management Support
Emphasize the patient’s central role in managing his/her health
Use effective self-management support strategies that include goal setting, action planning and problem-solving
Organize internal and community resources to provide ongoing self-management support to patients

15. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

16. Six Focal Areas Decision Support
Embed evidence-based guidelines into daily clinical practice
Share evidence-based guidelines and information with patients to encourage their participation
Integrate specialist expertise and primary care

17. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

18. Six Focal Areas Delivery System Design
Define roles and distribute tasks among team members
Use planned interactions to support evidence-based care
Ensure regular follow-up by the care team
Give care that patients understand and that fits with their cultural background

19. Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive
COMMUNITY
Health Care Organizations
Self- Management Support
Clinical Information System
Resources & Policies
Delivery System Design
Decision
Support
Informed,
Empowered
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes

20. Six Focal Areas Clinical Information Systems
Provide timely reminders for providers and patients
Identify subpopulations for proactive care
Facilitate individual care planning
Share information with patients and providers to coordinate care
Monitor performance of practice team and care system

21. Assessment of Chronic Illness Survey
Tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness
Evaluates the organization of care rather than outcome, process or productivity measures
Provides baseline information and guidance as to the system changes needed to improve care
Survey questions focus on the six areas of system change identified by the Chronic Care Model as influencing quality of care

22. Assessment of Chronic Care1 2 3 4 5 6 7 8 9 10 11
N=90
Mean Rating (0-11)
Organization
Self-Management
Decision Support
Community Linkages
Information Systems
Delivery System Redesign

23. Questions