The Chronic Care Model is a framework for improving the delivery of chronic care services in the health care system. It was developed by the MacColl Institute for Healthcare Innovation, based at the Group Health Cooperative in Seattle, Washington. The model emphasizes the need for a comprehensive approach to care that includes proactive care management, self-management support, delivery system design, and decision support.
The four principles of the Chronic Care Model are:
1. Proactive Care Management: Proactive care management incorporates clinical decision support, care coordination, and patient education to ensure that patients receive the right care at the right time. This includes understanding the patient’s medical history, engaging the patient in their care, and providing timely and appropriate follow-up.
2. Self-Management Support: Self-management support involves equipping patients with the skills, knowledge, and resources to manage their own health and care. This includes providing patients with the education and tools to understand their condition, manage their medications, make healthy lifestyle choices, and manage their health over time.
3. Delivery System Design: Delivery system design focuses on improving the quality and effectiveness of care delivery. This includes improving the flow of information within the health care system, developing systems to track and monitor patient health and care, and integrating services across different providers.
4. Decision Support: Decision support is an evidence-based approach to care that is customized to the individual patient. This includes using evidence-based guidelines, protocols, and algorithms to inform the decision-making process. It also includes providing timely feedback to clinicians to help them make better decisions.
The Chronic Care Model has been shown to be an effective approach to improving the quality of care and patient outcomes. By incorporating these four principles, health care providers can create a comprehensive system of care that is tailored to the individual needs of each patient.