Chronic Care Model As a Framework to Improve Diabetes Care at an Academic Internal Medicine Faculty-Resident Practice

Abstract

We implemented a quality improvement project for diabetes care in a faculty-resident internal medicine practice, using the Chronic Care Model framework. We created a planned visit clinic, used a stepwise medication algorithm, and self-management support. The intervention was effective for patients with glycohemoglobin A1c levels 10 or above (P = .0075) when compared with usual care after adjusting for all significant predictors. Compliance with foot examinations increased by 72% (P < .0001) and pneumococcal vaccinations by 25% (P = .0115). We believe that the Chronic Care Model can be successfully integrated into faculty-resident practices and provides a model for further exploration into disease management education in academic settings.

Paljon sosiaali- ja terveyspalveluja käyttävien asiakkaiden palveluiden toteutuminen – työntekijöiden ja johtavien viranhaltijoiden haastattelututkimus

“…Pitkäaikaissairaiden hoidon organisointi Terveyshyötymallin (Chronic Care Model, CCM) mukaan parantaa pitkä-aikaissairauksien hoitoa ja lisää terveyshyötyä (10,11,12,13) sekä vähentää terveydenhuollon kustannuksia (14,15). Mallissa on keskeistä hyvä vuorovaikutussuhde hoitavan tiimin ja asiakkaiden välillä.…”

“…The results of the research help us to develop the services of frequent attenders in order to meet their needs better. The informants (14) in the study were eleven professional working in primary health care and social services and their superiors (n=3). The qualitative research data was gathered by group interviews (n=4).…”

“…A r t i k k e l i SOSIAALILÄÄKETIETEELLINEN AIKAKAUSLEHTI 2017: 54: [6][7][8][9][10][11][12][13][14][15][16][17] Paljon sosiaali-ja terveyspalveluja käyttävien asiakkaiden palveluiden toteutuminen -työntekijöiden ja johtavien viranhaltijoiden haastattelututkimus Tutkimuksen tarkoitus oli kuvata, miten paljon palveluja käyttävien asiakkaiden sosiaalija terveydenhuollon palvelut toteutuivat erään peruspalvelukuntayhtymän työntekijöiden ja johtavien viranhaltioiden näkökulmasta. Tutkimuksen tavoitteena oli kehittää paljon palveluja käyttävien asiakkaiden palveluja.…”

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

“…Also as Wagner defined [10], the CCMs could "reorganize team function and practice systems; develop and implement evidence-based guidelines and support those guidelines through provider education, reminders, and increased interaction between generalists and specialists; as well as enhance information systems to facilitate the development of disease registries, tracking system, and reminders and to give feedback on performance." So far, CCM has been adopted and implemented in many areas of medical practice [10,12,[18][19][20][21][22][23][24].…”

A Research Program on Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH): An International Collaboration

“…The CCM is based on six essential elements that are fundamental to effective partnerships between informed, activated patients and prepared, proactive practice teams: 1) community resources and policies; 2) health care organization; 3) self-management support; 4) delivery system design; 5) decision support; and 6) clinical information systems. However, the focus of chronic care management is often centred on the management of single diseases for individuals rather than on the provision of population-based, comprehensive and integrated health and social care services for people with multiple conditions and their families [11011121314]. In this study we use the CCM to understand and characterize the delivery of ICBPHC.…”