The Chronic Care Model and the Transformation of Primary Care

2016 ◽  
pp. 89-96 ◽  
Author(s):  
Thomas Bodenheimer ◽  
Rachel Willard-Grace
Keyword(s):  
Primary Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Care Model

scholarly journals Barriers and Facilitators towards an Integrated Chronic Care Model as experienced by primary care health providers

2016 ◽  
Vol 16 (6) ◽  
pp. 78 ◽  
Author(s):  
Geert Goderis ◽  
Gunther D'hanis ◽  
Gert Merckx ◽  
Wim Verhoevven ◽  
Pierre Sijbers ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Barriers And Facilitators ◽  
Health Providers ◽  
Care Model ◽  
Primary Care Health ◽  
Care Health

scholarly journals Using Mobile Health to Support the Chronic Care Model: Developing an Institutional Initiative

2012 ◽  
Vol 2012 ◽  
pp. 1-8 ◽  
Author(s):  
Shantanu Nundy ◽  
Jonathan J. Dick ◽  
Anna P. Goddu ◽  
Patrick Hogan ◽  
Chen-Yuan E. Lu ◽  
...  
Keyword(s):  
Primary Care ◽  
Health System ◽  
Health Plan ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Primary Care Team ◽  
Self Management ◽  
Management Support ◽  
Care Model ◽  
Team Based Care

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation.Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time.Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral.Conclusion. Our innovative program enables the existing health system to support ade novocare management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

scholarly journals Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care

2010 ◽  
Vol 23 (3) ◽  
pp. 295-305 ◽  
Author(s):  
P. A. O. Strickland ◽  
S. V. Hudson ◽  
A. Piasecki ◽  
K. Hahn ◽  
D. Cohen ◽  
...  
Keyword(s):  
Primary Care ◽  
Diabetes Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Care Model ◽  
Behavioral Counseling

Kansas Primary Care Weighs In: A Pilot Randomized Trial of a Chronic Care Model Program for Obesity in 3 Rural Kansas Primary Care Practices

2008 ◽  
Vol 24 (2) ◽  
pp. 125-132 ◽  
Author(s):  
Andrea C. Ely ◽  
Angela Banitt ◽  
Christie Befort ◽  
Qing Hou ◽  
Paula C. Rhode ◽  
...  
Keyword(s):  
Primary Care ◽  
Randomized Trial ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Model Program ◽  
Care Model ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review

2018 ◽  
Vol 258 ◽  
pp. 279-288 ◽  
Author(s):  
E.K. Yeoh ◽  
Martin C.S. Wong ◽  
Eliza L.Y. Wong ◽  
Carrie Yam ◽  
C.M. Poon ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Care Model

scholarly journals A Chronic Care Model Program Incorporating Group Office Visits for Obesity Treatment in Primary Care

2011 ◽  
Vol 4 (4) ◽  
pp. 87-98 ◽  
Author(s):  
Andrea C Ely ◽  
Christie A Befort ◽  
Angela Banitt Duncan ◽  
Jianghua He ◽  
Cheryl Gibson ◽  
...  
Keyword(s):  
Primary Care ◽  
Weight Change ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Primary Care Providers ◽  
Obesity Treatment ◽  
Care Providers ◽  
Office Visits ◽  
Care Model ◽  
Weight Control Behaviors

Background. Obesity is a chronic disease of epidemic proportions. Primary care providers are on the front line of diagnosing and treating obesity and need better tools to deliver top-notch obesity care. Methods. A pilot randomized trial was conducted to test a chronic care model (CCM) program for obesity compared to usual care. Primary care patients, 18 years and older, with a body mass index (BMI) between 27 and 45 were enrolled. Sixteen weekly 90-minute group office visits were structured with the first 30 minutes encompassing individualized clinical assessments and the final 60 minutes containing the group-based standardized intensive lifestyle training. The primary outcome was weight change at 16 weeks. Secondary outcomes were weight change at 24 weeks, change in diet and physical activity behaviors, self-efficacy for weight control behaviors, and physiologic markers of cardiovascular risk at 16 and 24 weeks. Results. The participants (19 in the active arm and 10 in the control arm) were 49.8 ± 11.5 years old (mean ± SD), 97% women, 55% white, and 41% black. Weight change in the control arm at week 16 was 0.25+ 2.21 kg (mean + SD) and that for the active arm was -5.74 + 4.50 kg (n=16). The difference between the two arms was significant (p = 0.0002). Both the intent-to-treat analysis using the last observation carried forward approach and the analysis including completers only provided similar siginificant results. Conclusions. This study demonstrated that a CCM program incorporating group office visits was feasible and effective for obesity treatment in primary care settings.

scholarly journals Reciprocal learning and chronic care model implementation in primary care: results from a new scale of learning in primary care

2011 ◽  
Vol 11 (1) ◽  
Author(s):  
Luci K Leykum ◽  
Ray Palmer ◽  
Holly Lanham ◽  
Michelle Jordan ◽  
Reuben R McDaniel ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Care Model ◽  
Reciprocal Learning

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

2006 ◽  
Vol 9 (1) ◽  
pp. 1-15 ◽  
Author(s):  
David A. Dorr ◽  
Adam Wilcox ◽  
Laurie Burns ◽  
Cherie P. Brunker ◽  
Scott P. Narus ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Care Model ◽  
Chronic Care ◽  
Care Model
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