Application of chronic care model for self-management of type 2 diabetes: focus on the middle-aged population of Pakistan

This article discusses the potential application of Chronic Care Model (CCM) for self-management of type 2 diabetes focusing on the middle-aged population of rural area of Pakistan. The article further highlights the variations of chronic care model and the evidence for its efficacy and elaborating the elements of the model that are used in primary health care. The features of Chronic Care Model (CCM) have been highlighted including the socio-ecological approach to diabetes self-management and community-based partnership for improving chronic disease management. The two components of the chronic care model such as patient self-management support (SMS) and delivery system design (DSD) have been proposed for type 2 diabetes patients in the middle-aged population of rural area of Pakistan to see the effectiveness of their intervention in improving the patient quality of life, risk behaviour and knowledge and adherence to treatment. The chronic care model offers an ideal framework to support diabetes self-management education and support because it provides a sound basis on which to promote self-management

Substance abuse: A chronic care perspective

This study provides an examination of the Chronic Care Model and its application to the treatment of substance abuse disorders. The hypothesis of the study was that elements of the Chronic Care Model are not being utilized within San Bernardino County\u27s system of care. The study was conducted by having Alcohol and other Drug Counselors throughout San Bernardino County complete the study\u27s 24-question quantitative survey. The purpose of this study is to add to the sparse literature related to the Chronic Care Model and its application to the alcohol and other drug (AOD) field. At this time the AOD field utilizes an acute care model which is ineffective for those treated for addiction

A multidisciplinary reference framework to support implementation and assessment of diabetes care in community settings: study design

Diabetes is a disease presenting multifaceted challenges. A holistic approach is needed to properly address it. The Chronic Care Model, worldwide reference for managing chronic disease in community settings, support implementation at micro-meso--macro level. We present a multi-disciplinary framework that support the uptake of the Chronic Care Model. This framework was tested to support the implementation of a research project focused on Diabetes Management through personal health systems

Chronic Care Model for Management of Diabetes Mellitus

Diabetes mellitus is a serious chronic disease affecting individuals at various stages of life. More than 114 million Americans are at risk of developing complications of diabetes. It is the leading cause of kidney failure, nontraumatic lower-limb amputations, heart disease, stroke, and new cases of blindness among adults in the United States. This quality improvement project sought to understand if important clinical indicators of diabetes mellitus such as HbA1c, blood pressure, serum cholesterol, high-density lipoprotein, low-density lipoprotein, serum creatinine; and estimated glomerular filtration rate would improve after implementation of a team-based guideline-informed approach to diabetes care management. The chronic care model (CCM) was the basis of the project and has been shown to improve the quality of diabetes care through greater attention to principles and care guidelines by multidisciplinary professional teams. Pre/post descriptive deidentified data were collected from initiation of the CCM project to three months’ post-project initiation. Out of the 14 participants from the practice site, all showed clinically relevant reduction less than or equal to 0.5% to 1% in HbA1c, serum cholesterol, and triglycerides without experiencing hypoglycemia on posttest. The project results may impact social change through the empowerment of patients as they become more engaged in their treatment plan and ability to make educated decisions. It can also benefit the organization and the healthcare professionals by creating a patient-first attitude to care and organizational structure

Chronic Care Model Staff Education and Adherence with End-Stage Renal Disease Patients

The management and treatment of chronic diseases, such as end-stage renal disease, is often unproductive because of patients\u27 poor adherence to treatment. The chronic care model toolkit is an Agency for Healthcare Research and Quality supported framework, associated with improved outcomes in patients living with chronic disease. The purpose of this project was to develop and plan an educational program using the chronic care model toolkit for the interdisciplinary clinical staff of a renal hemodialysis center. The goal of this project was to adapt team building between patients and their clinicians through the use of the chronic care model in order to improve patients\u27 adherence to treatment. The educational program materials were developed, including a plan for future implementation over 6 weeks in 2-hour twice-weekly sessions. Program planning accounted for the mixed roles and responsibilities of the interdisciplinary clinical team members, who will share their knowledge among the team and act as patient advisors. The pretest and posttest materials were developed from the toolkit Team Health Audit Questionnaire, which can be used to evaluate staff learning after the program is delivered. Existing clinical metrics are tracked through a Quality Assessment Performance Improvement measure, which will be used to evaluate potential long term influences of the program on patient adherence and outcomes. The project may contribute to social change in practice by enhancing teamwork that has the potential to improve clinical outcomes. Future research should include longitudinal studies on team building using the chronic care model toolkit to determine if its adaption enhances team effort and contributes to a collaborative workforce that improves clinical outcomes

The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Diabetes is a major challenge for the health care system and especially for the primary care provider. The Chronic Care Model represents an evidence-based framework for the care for chronically ill. An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters. However, most of these findings have been performed in settings different from the Swiss health care system which is dominated by single handed practices.</p> <p>Methods/Design</p> <p>CARAT is a cluster randomized controlled trial with general practitioners as the unit of randomization (trial registration: ISRCTN05947538). The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year (primary outcome). Furthermore, we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure (<130/80), HbA1c (=<6.5%) and low-density lipoprotein-cholesterol (<2.6 mmol/l), increases patients' quality of life (SF-36) and several evidence-based quality indicators for diabetes care. These improvements in care will be experienced by the patients (PACIC-5A) as well as by the practice team (ACIC). According to the power calculation, 28 general practitioners will be randomized either to the intervention group or to the control group. Each general practitioner will include 12 patients suffering from diabetes type II. In the intervention group the general practitioner as well as the practice nurse will be trained to perform care for diabetes patients according to the Chronic Care Model in teamwork. In the control group no intervention will be applied at all and patients will be treated as usual. Measurements (pre-data-collection) will take place in months II-IV, starting in February 2010. Follow-up data will be collected after 1 year.</p> <p>Discussion</p> <p>This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach. If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to redesign care in Switzerland.</p

Information technologies that facilitate care coordination: provider and patient perspectives

Health information technology is a core infrastructure for the chronic care model, integrated care, and other organized care delivery models. From the provider perspective, health information exchange (HIE) helps aggregate and share information about a patient or population from several sources. HIE technologies include direct messages, transfer of care, and event notification services. From the patient perspective, personal health records, secure messaging, text messages, and other mHealth applications may coordinate patients and providers. Patient-reported outcomes and social media technologies enable patients to share health information with many stakeholders, including providers, caregivers, and other patients. An information architecture that integrates personal health record and mHealth applications, with HIEs that combine the electronic health records of multiple healthcare systems will create a rich, dynamic ecosystem for patient collaboration

Implementing a technology-based chronic care model: A case study

It currently estimated that three in five Canadians suffer from some form of chronic disease with recent trends showing rates of such conditions still rising. Moreover, in Canada, the cost of treating chronic illness is increasing faster than national economic growth. In response to this growing concern, various programs and initiatives have been implemented to mitigate the personal, social and economic effects of chronic disease. The objective of this study is to identify factors influencing the implementation of technology-based chronic care model within the team-based, primary care setting. Data for this single-embedded case study was collected using a variety of methods including; observation, semi-structured interviews, and document analysis. Coding of data was conducted using a deductive code list based on the Consolidated Framework for Implementation Research. Coder reliability was tested with the assistance of two additional coders. The findings from this study will provide case-specific glance into various factors contributing to the implementation of a chronic care model in the team-based, primary care setting. While each healthcare team is unique in composition and is influenced by different environmental and contextual factors, the aim of this study is to identify elements of program implementation that could be improved in future efforts

Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes

Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient’s health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD