The chronic care model refers to a widely-used framework for organizing and providing care for people with chronic disease. (ICIC, 2018) In this model, care is provided within a primary care setting, operating with a strategy of bringing together the patient, provider and system interventions necessary to accomplish the overall goal of improving care for chronic illness. (Medscape, 2006).
History and Elements of the Chronic Care Model
The model was initially created in the mid-1990s by the staff at the MacColl Center for Health Care Innovation at Group Health Research Institute, led by Edward H. Wagner, MD, MPH. They distilled information from available sources on strategies for chronic illness management into a more codified format. The model was further refined in 1997 with input from a large panel of experts. In 1998, The Robert Wood Johnson Foundation funded tests of the model nationally across various health care settings, creating the program “Improving Chronic Illness Care” (ICIC). In 2003, ICIC and a small group of experts updated the model to include more specific concepts within the six elements.
The chronic care model consists of six components of healthcare delivery. They are:
- Health System/Organizational Support – Create a culture, organization and mechanisms that promote safe, high quality care.
- Visibly support improvement at all levels, beginning with leadershipPromote effective improvement strategies designed for comprehensive system change
- Encourage open and systematic handling of errors and quality problems to improve care
- Provide incentives based on quality of care
- Develop agreements that support care coordination within and across organizations
- Clinical Information Systems – Organize patient and population data to facilitate efficient and effective care.
- Provide timely reminders for providers and patients
- Identify relevant subpopulations for proactive care
- Facilitate individual patient care planning
- Share information with patients and providers to coordinate care
- Monitor performance of practice team and care system
- Delivery System Design – Assure the delivery of effective, efficient clinical care and self-management support.
- Define roles and distribute tasks among team members
- Use planned interactions to support evidence-based care
- Provide clinical case management services for complex patients
- Ensure regular follow-up by the care team
- Give care that patients understand and that fits with their cultural background
- Decision Support – Promote clinical care that is consistent with scientific evidence and patient preferences.
- Embed evidence-based guidelines into daily clinical practice
- Share evidence-based guidelines and information with patients to encourage their participation
- Use proven provider education methods
- Integrate specialist expertise and primary care
- Self-Management Support – Empower and prepare patients to manage their health and health care.
- Emphasize the patient’s central role in managing their health
- Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
- Organize internal and community resources to provide ongoing self-management support to patients
- Community Resources – Mobilize community resources to meet needs of patients.
- Encourage patients to participate in effective community programs
- Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
- Advocate for policies to improve patient care
Improving Chronic Illness Care, 2003
Why is the Chronic Care Model important?
Chronic diseases and their management are quickly becoming one of the largest elements of primary care. The chronic care model has been used widely for many years in a variety of settings. Though many providers have struggled to implement the chronic care model in a way that is cost effective, there is now significant evidence that the model is effective in both chronic care management and in practice improvement. (NCBI, 2015)
How does Chronic Care Management fit into the Chronic Care Model?
Chronic care management refers to care coordination provided outside of the regular office visit, for patients with multiple chronic conditions. It is rooted in the chronic care model, and can be the process through which many crucial aspects of that framework are implemented. Chronic care management is a critical piece of an overarching chronic care improvement strategy, and can help providers push past the barriers in improving patient care and outcomes.
In 2015, Medicare began offering monthly reimbursements for chronic care management services. The path to improved care for chronic conditions has become easier, with a clear and effective framework for quality care and reimbursements for chronic care management.
How can BlueFish Medical help you move towards the Chronic Care Model?
BlueFish Medical provide chronic care management services. Some of the biggest obstacles faced by providers wishing to implement the chronic care model – limited staffing and financial resources – can be alleviated with our help.
BlueFish can extend your medical practice by identifying eligible patients, recruiting and signing them up, creating customized care plans, delivering care with our nursing staff and then billing for the services.
By managing a practice’s CCM services, BlueFish is freeing up providers to focus on face-to-face encounters, while also realizing reimbursements for non face-to-face visits to which they no longer have to dedicate their time.
If you’d like to learn more about how BlueFish Medical can help you introduce chronic care management services to your practice, fill out the form below.
Sources:
Steps for Improvement (1): Models. (2018). Improving Chronic Illness Care. Retrieved from: http://www.improvingchroniccare.org/index.php?p=1:_Models&s=363
The Chronic Care Model: Description and Application for Practice. (2006). Medscape. Retrieved from: https://www.medscape.com/viewarticle/549040
Model Elements. (2003). Improving Chronic Illness Care. Retrieved from: http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18
Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. (2015) National Center for Biotechnology Information. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4448852/