Home-Based Chronic Care

Abstract

The Chronic Care Model (CCM) developed by is an influential and accepted guide for the care of patients with chronic disease. Wagner acknowledges a current healthcare focus on acute care needs that often circumvents chronic care coordination. He identifies the need for a "division of labor" to assist the primary care physician with this neglected function. This article posits that the role of chronic care coordination assistance and disease management fits within the purview of home healthcare and should be central to home health chronic care delivery. An expanded Home-Based Chronic Care Model (HBCCM) is described that builds on Wagner's model and integrates salient theories from fields beyond medicine. The expanded model maximizes the potential for disease self-management success and is intended to provide a foundation for home health's integral role in chronic disease management.

Identification of mechanisms enabling integrated care for patients with chronic diseases: a literature review

“…Of the selected studies, only five were based on empirical data [15, 17, 31, 33, 39]. Of the remaining 29 studies, 19 were narrative reviews [4, 14, 18, 22–24, 28, 30, 34, 36–38, 40–46].…”

Testing the chronic care model for depression in homebound older adults.

“…A high-touch delivery system as suggested in the original CCM will be important (Wagner, Austin, & Van Korff, 1996a. The CCM developed for home care recipients by Suter and colleagues (Suter, Hennessey, Florez, & Newton Suter, 2011;Suter et al, 2008) also suggests that providing more visits is important for providing quality care. This model also recommends that health care offer more services, such as mental health and primary care.…”

“…Those who are depressed may benefit from the chronic illness self-management training advocated in CCM models (Bodenheimer et al, 2002;Suter et al, 2011;Suter et al, 2008;Wagner et al, 1996aWagner et al, , 1996b because they are more likely to experience improvement in self-efficacy (Jerant, Kravitz, Moore-Hill, & Franks, 2008).…”

“…Technology can be effective in helping to manage depression and chronic illnesses in homebound older adults (Choi et al, 2012b;Gaikwad & Warren, 2009;Nakamura, Takano, & Akao, 1999;Sheeran et al, 2011), and it is also recommended in many CCMs (Suter et al, 2011;Suter et al, 2008;Wagner et al, 2001Wagner et al, , 1996aWagner et al, , 1996b.…”

“…Three CCMs have been developed for older adults including one for providing frail older adults primary care at home (Muntinga et al, 2012), one that was designed for use with homebound older adults (Suter, Hennessey, Florez, & Newton Suter, 2011;Suter et al, 2008), and the VA's model of Home-Based Primary Care (HBPC; Hicken & Plowhead, 2010;Wharton et al, 2012). Although only the VA model thoroughly accounts for depression, these CCMs include many pieces that are useful for managing depression in homebound older adults.…”