The Chronic Care Model

The chronic care model (CCM) has been proposed as a useful framework for considering the system changes necessary to construct a health care system that proactively promotes healthy behaviors and trains clinician and patients to work as partners in a collaborative care process (Glasgow et al., 2001) (Figure 6-3). The CCM identifies six essential elements of a health care system that together foster interactions between an informed, activated patient and a prepared, proactive health care team. The model defines six broad dimensions that must be considered when redesigning systems of care: organization of care, clinical information systems, delivery-system design, decision support, self-management support, and community resources (Wagner, 1998). As a model, the CCM does not provide a specific set of interventions; instead, it acts as a framework within

Table 6-7 Theories and Models of Individual Behavior Change

Theory or Model

Focus

Key Concepts

Health belief model

Peoples' perceptions of the threat of a health problem and appraisal of the behavior recommended to prevent or manage the problem.

Perceived susceptibility Perceived severity Perceived benefits of action

Perceived barriers to action

Cues to action Self-efficacy

Theory of reasoned action, theory of planned behavior

People are rational beings whose intention to perform a behavior is strongly related to its actual performance through beliefs, attitudes, subjective norms, and perceived behavioral control.

Behavioral intention Subjective norms Attitudes

Perceived behavioral control

Stages of change, transtheoretical model

Readiness to change or attempt to change a health behavior varies among individuals and within an individual over time. Relapse is a common occurrence and part of the normal process of change.

Precontemplation Contemplation Preparation Action

Maintenance Relapse

Social cognitive theory, social learning theory

Behavior is explained by dynamic interaction among personal factors, environmental influences, and behavior.

Observational learning

Reciprocal determinism Outcome expectancy Behavioral capacity Self-efficacy Reinforcement

Modified from Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002;22:267-284.

Modified from Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002;22:267-284.

CHRONIC CARE MODEL

CHRONIC CARE MODEL

Improved outcomes

Figure 6-3 The chronic care model. (Modified from Wagner EH. Chronic disease management: what will it take to improve chronic illness? Effect Clin Pract 1998;1:2-4.)

Improved outcomes

Figure 6-3 The chronic care model. (Modified from Wagner EH. Chronic disease management: what will it take to improve chronic illness? Effect Clin Pract 1998;1:2-4.)

which improvement strategies can be tailored to local conditions.

In an individual office, the application of the CCM toward improving the quality of preventive services may lead to any of the following:

• Developing a patient registry for child and adult immunizations (i.e., clinical information system).

• Implementing standing orders that all patients with diabetes receive a home glucose monitor and meet with a nurse educator (i.e., delivery system design).

• Referring all prenatal patients to a local La Leche League meeting (i.e., community resources).

• Designing a prompt to cue physicians to schedule a mammogram (i.e., decision support).

• Integrating achievement of prevention goals into physician performance bonuses (i.e., health system organization).

• Training physicians to use the techniques of motivational interviewing to set goals in collaboration with patients and identify personal barriers and supports after advising smokers to quit (i.e., self-management support).

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