Among the many models adopted into PHM efforts, the collaborative chronic care model (CCM) framework is successful at managing diabetes and other chronic diseases among affected populations. There are six elements that are essential to the CCM: (a) health systems, (b) delivery system design, (c) decision support, (d) clinical information systems, (e) community resources and policies, and (f) self-management support (Improving Chronic Illness Care, 2003; see Appendix, Terms and Definitions).
The GHFHC’s will follow the CCM for its health improvement plan based on certain assumptions about the plan. These assumptions are that the plan (a) needs to be sustained for a long time, (b) needs to comply with evidence-based guidelines for patient care, (c) needs to focus on patient education and lifestyle improvement, (d) needs to provide affordable and cost-effective care for AIs, and (e) needs to be culturally sensitive and equitable for disadvantaged community members.
The CCM’s six elements complement these assumptions and when the model is implemented in a PHM, the CCM will allow an informed, active community to productively interact with a proactive, prepared clinical team to achieve improved outcomes. Key components of the plan that are consistent with the CCM elements and the GHFHC’s assumptions are as follows:
- establishing a system for collecting data and tracking health outcomes among AI patients;
- establishing an operational leadership that will change staff management policies to ethnically match ethnicity and language of AI patients;
- training all health care professionals on the CCM and cultural and linguistic competence;
- sharing reports, lab-work, and epidemiological data with local health systems;
- identifying local resources such as community health centers, YMCAs, religious centers, and senior centers that can help connect patients with the GHFHC; and
- planning regular meetings for all stakeholders to resolve issues, discuss outcomes, and make recommendations.
The different components in the plan will enable health care professionals in diagnosing widespread diabetes in the AI community and ensure that cultural competence is deployed at the patient, health care professional, organizational, and systems levels. The next section will discuss why the CCM was selected over other community-based population health management models. Relevant evidence and examples will be provided.
Value and Relevance of the Chronic Care Model
Since its inception more than 15 years ago, the chronic care model has been for diabetes care in health care organizations across the United States with positive outcomes (Baptista et al., 2016). Most of the evidence supporting the model comes from randomized control trials (RCTs), qualitative reviews, meta-analyses, and systematic reviews of articles on the CCM in health care organizations. The results of one systematic review of 16 studies on the CCM application revealed better diabetes management programs in several health organizations (Stellefson, Dipnarine, & Stopka,2013).
Organizational leaders used the CCM to initiate system-level changes that improved delivery of diabetes care to patients. The organizations introduced disease registries and electronic records to establish patient-centered goals, educate patients on self-management, and train health care professionals in evidence-based care.
Another study evaluated the success of Project Dulce, a CCM-based diabetes care program developed by the Scripps Whittier Diabetes Institute in collaboration with San Diego County, San Diego State University, and federally qualified health centers (Philis-Tsimikas & Gallo, 2014). The project used specially trained teams and peer educators to implement the CCM elements in an ethnically and racially diverse community. The results showed significant cost-effectiveness, hospitalizations and emergency visits reduced.
While the CCM has many merits, there are conflicts in the data provided by the aforementioned studies. Health care organizations implement only one or two elements such as delivery design systems or self-management rather than the combined implementation of all six elements. As a result, it is difficult to determine the overall impact of the CCM or identify the combinations of elements that are ideal (Davy et al., 2015).
Other conflicting problems are related to the study process of RCTs: participants were sometimes aware of their participation in trials, follow-up periods and sample sizes were insufficient, and study nurses were inadequately trained (Baptista et al.,2016).
Despite these problems, the CCM remains a popular model compared to the acute care model of case management. While the two are similar in terms of care coordinat
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