Chronic care models are designed to optimize the care of patients who have or are at significant risk for chronic conditions. The prevalence of chronic conditions has been increasing due to the aging of the population and rising levels of lifestyle-related risk factors. Projecting these trends forward, the growing burden of disease and costs could be crippling. Consequently, chronic care improvement is a high priority for population health management.
Community Health Solutions has substantial experience and an extensive toolkit for chronic care improvement. Our approach relies heavily on the Chronic Care Model as developed by the MacColl Institute and as tested in a wide range of settings. The Chronic Care Model is designed to optimize the capabilities and interactions between six key elements, including:
- Health System Organization
- Delivery System Design
- Decision Support
- Clinical Information Systems
- Self Management Supports
- Community Policies and Resources.
The Chronic Care Model aligns with principles of population health management, the PCMH model, and other patient-centered models of care. In fact, many primary care practices that do see strategic value in seeking PCMH recognition choose instead to build their chronic care capacity based on the Chronic Care Model. Community Health Solutions has helped scores of organizations undertake chronic care improvement initiatives based on the Chronic Care Model, including private practices, health systems, federally qualified health centers, and free clinics. In a typical engagement we help the organization:
- Define objectives for chronic care improvement based on assessment of current capabilities;
- Design strategies for building chronic care capabilities;
- Build organizational capacity for implementing chronic care improvement; and
- Execute for improved quality and outcomes.
We use the power of Action Learning to help clinical organizations assess needs, design strategies, build capacity, optimize performance, and demonstrate value. Please click here to learn more our Action Learning supports. You can also contact us for a no-obligation discussion of how we can help your organization achieve its goals.