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May 8, 2023

Six Chronic Care Management Concepts
and why they matter

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Six Chronic Care Management Concepts


Chronic care management is a comprehensive approach to caring for an increasingly more extensive group of patients who might develop chronic conditions earlier in life. Six foundational concepts help us understand chronic care management from a systems approach. When healthcare providers keep these concepts in focus while delivering care, they make a meaningful impact on the patients and the care they receive.

Here are six chronic care management concepts:

1. Organizational Support

The healthcare system provides organizational support for the processes that deliver services. Everyone benefits when a healthcare system has a positive culture that delivers healthy outcomes. A willingness to continually look for ways to improve outcomes should run throughout the work culture. This attention requires leadership that helps the organization succeed and gives everyone a stake in the outcomes with incentives.

2. Health Information Systems

Today's care teams use comprehensive electronic health records that do more than record patient information and vital signs. A patient's records are instructions for managing their care. The system helps caregivers deliver services that change patient outcomes, from medical treatments to wellness advice.

The best clinical information systems help providers make decisions that help patients and help the practice run efficiently. These electronic records systems manage information related to the entire patient record and should include CCM initiatives. Features of a sound medical records system include finding information quickly and seamless integration with other data sets that help caregivers give evidence-based treatment and advice. The system also reaches out to patients to help them stay on track for healthy living.

3. Care Delivery System Design

A care delivery system attentive to patient needs looks for new ways to reach out to patients that meet them at their level. For instance, some care teams may have more responsibility because they interact directly with their patients.

The CCM model fosters working relationships between patients and caregivers so that both benefit from the partnership. Only introduce a new team member to a care team after discussing it with the patient. When combined with positive organizational support, the patient and the care team become empowered with motivation to be better physically and mentally.

4. Decision Support

Rather than final decisions falling on one individual, a chronic care management team fosters working relationships within the group, leading to a consensus on what's best for the patient. This encourages team collaboration in finding the best way to help the patient.

Team members should have guidelines and best practices for caring for patients across multiple delivery points. The decision support, the organizational culture, and the information system work together to provide the best situations for making necessary consensus decisions.

5. Patient Self-Care Support

An effective CCM model encourages patient participation in self-care by educating them on their role. Strategies like goal setting, action planning, problem-solving, and follow-up visits help patients take control of their care outcomes.

6. Community Resources

Communities provide an often underutilized stream of support for people with chronic conditions. The CCM model fits into a community mission and can be adjusted to serve local residents who might not otherwise have access to care.

When used together, the six concepts form a conceptual framework for chronic care management that ensures equitable service delivery.

In order to meet specific performance metrics, providers must find ways to emphasize clinical efficiency and improve health outcomes. Care coordination offers a broad response to these challenges. But specific care management and wellness programs can be more exact in how they address value-based care.

If you would like to learn more about the relationship between Care Coordination and Value-Based Care download our e-book

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