Effects of a Primary Care–Based Chronic Care Model on Diabetes Self-Management, Diabetes Distress, and Health Care Experience

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.

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The Chronic Care Model and Chronic Condition Self-Management: An Introduction for Audiologists

Seminars in Hearing ◽

10.1055/s-0038-1676780 ◽

2019 ◽

Vol 40 (01) ◽

pp. 007-025 ◽

Cited By ~ 4

Author(s):

Louise Hickson ◽

Gitte Keidser ◽

Carly Meyer ◽

Elizabeth Convery

Keyword(s):

Health Care ◽

Chronic Care Model ◽

Chronic Conditions ◽

Chronic Condition ◽

Chronic Care ◽

Clinical Care ◽

Self Management ◽

Management Support ◽

Care Model ◽

Hearing Health

AbstractHearing health care is biomedically focused, device-centered, and clinician-led. There is emerging evidence that these characteristics—all of which are hallmarks of a health care system designed to address acute, rather than chronic, conditions—may contribute to low rates of help-seeking and hearing rehabilitation uptake among adults with hearing loss. In this review, we introduce audiologists to the Chronic Care Model, an organizational framework that describes best-practice clinical care for chronic conditions, and suggest that it may be a viable model for hearing health care to adopt. We further introduce the concept of chronic condition self-management, a key component of chronic care that refers to the knowledge and skills patients use to manage the effects of a chronic condition on all aspects of daily life. Drawing on the chronic condition evidence base, we demonstrate a link between the provision of effective self-management support and improved clinical outcomes and discuss validated methods with which clinicians can support the acquisition and application of self-management skills in their patients. We examine the extent to which elements of chronic condition self-management have been integrated into clinical practice in audiology and suggest directions for further research in this area.

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Care production for tuberculosis cases:analysis according to the elements of the Chronic Care Model

Revista da Escola de Enfermagem da USP ◽

10.1590/s0080-623420160000200009 ◽

2016 ◽

Vol 50 (2) ◽

pp. 239-246 ◽

Cited By ~ 6

Author(s):

Daiane Medeiros da Silva ◽

Hérika Brito Gomes de Farias ◽

Tereza Cristina Scatena Villa ◽

Lenilde Duarte de Sá ◽

Maria Eugênia Firmino Brunello ◽

...

Keyword(s):

Health Care ◽

Primary Health Care ◽

Chronic Care Model ◽

Health Care Services ◽

Chronic Care ◽

Capital City ◽

Care Model ◽

Care Services ◽

Primary Health ◽

Primary Health Care Services

Abstract OBJECTIVE: To analyze the care provided to tuberculosis cases in primary health care services according to the elements of the Chronic Care Model. METHOD: Cross-sectional study conducted in a capital city of the northeastern region of Brazil involving 83 Family Health Strategy professionals.A structured tool adapted to tuberculosis-related care in Brazil was applied.Analysis was based on the development of indicators with capacity to produce care varying between limited and optimum. RESULTS: The organization of care for tuberculosis and supported self-care presented reasonable capacity.In the coordination with the community, the presence of the community agent presented optimum capacity.Partnership with organizations of the community and involvement of experts presented limited capacity.The qualification of professionals, the system for scheduling and monitoring tuberculosis in the community, and the clinical information system presented basic capacity. CONCLUSION: The capacity of the primary health care services to produce tuberculosis-related care according to the elements of the Chronic Care Model is still limited.Overcoming the fragmentation of care and prioritizing a systemic operation between actions and services of the health care network remains as a major challenge.

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

International Journal of Integrated Care ◽

10.5334/ijic.2626 ◽

2016 ◽

Vol 16 (6) ◽

pp. 78 ◽

Cited By ~ 2

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

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Recreation and collaboration within the Expanded Chronic Care Model: working towards social transformation

Health Promotion International ◽

10.1093/heapro/daz134 ◽

2020 ◽

Vol 35 (6) ◽

pp. 1531-1542

Author(s):

Susan L Hutchinson ◽

Heidi Lauckner

Keyword(s):

Social Change ◽

Chronic Care Model ◽

Social Transformation ◽

Chronic Conditions ◽

Chronic Condition ◽

Chronic Care ◽

Self Management ◽

Care Model ◽

Community Based ◽

Community Recreation

Abstract Assisting people to live well with a chronic physical or mental health condition requires the creation of intersectoral community-based supports for chronic condition self-management. One important but underutilized resource for supporting chronic condition self-management in the community is recreation, which refers to relatively self-determined and enjoyable physical, social or expressive everyday activities. The Expanded Chronic Care Model (ECCM) provides a framework for identifying systems-level strategies to support self-management through increased access to community recreation opportunities. In this article, an occupation-based social transformation approach, which involves examining assumptions, considering contexts of daily activities and partnering to create meaningful social change, is used to examine the ECCM. Recommendations related to strengthening social change with a specific focus on collaborations and networks through recreation are provided. Through such collaborations, self-management of chronic conditions in community recreation contexts is advanced. Health providers and community-based recreation services providers are invited to be part of these intersectoral changes that will promote health amongst those living with chronic conditions.

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