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Rural Health Information Hub

Chronic Care Model

The Chronic Care Model (CCM) is a framework for improving the quality of chronic disease management delivered to patients. The CCM provides evidence-based guidelines that can be implemented to improve chronic disease care within different components of a healthcare system, which include the community, health system, self-management support, delivery system design, and decision support and clinical information systems. The model highlights how improved patient outcomes are the result of coordinated, trained, and proactive healthcare teams working closely with patients and their families/caregivers.

CCM was created over 25 years ago and has been adapted and used throughout the country and world. The structure and delivery of CCM programs vary. Typical components include providing information about the disease(s), offering education about behavior change, and providing information about medication adherence and management.

Examples of Rural Programs Using the Chronic Care Model (CCM)

  • The Health Wagon provides comprehensive healthcare services to people with chronic diseases in Southwestern Virginia. Using a nurse practitioner care coordinator, the Health Wagon uses the chronic care model — including coordination with an endocrinology clinic for specialized diabetes care — to reach patients with diabetes and other chronic diseases.
  • EnhanceWellness (EW) is an evidence-based and patient-centered program, based on the CCM, that pairs older patients who have a chronic disease and/or disability with a personal health coach. The health coaches work with healthcare systems to connect patients to services and support groups to improve quality of life. Personal health coaches can be social workers, nurses, or community health workers. The program can be delivered in person or remotely, is adapted to different languages, and has been implemented in different parts of the country. EW uses assessment tools to help participants develop action plans with their coaches to make improvements to their health.
  • Health West in Power County, Idaho is using CCM and care coordination — specifically, the patient-centered medical home model — to help patients living with diabetes, heart disease, and other chronic diseases. The program is delivering education on the ABCs of heart health, and other activities, to help patients manage illnesses and improve outcomes.
  • The Oswego Health Care Management program was developed to improve care coordination, access to care, and outcomes for people with complex medical and behavioral health conditions and who have or are at risk of heart disease. Nurse care managers work with patients and their primary care teams to support participants with managing their illness after an inpatient hospital stay. The program is working to integrate care for patients and to make system-level changes to provide chronic disease care driven by patient goals and needs.
  • The 4 Hearts Sake project is being implemented in rural Kentucky through the Community Medical Clinic and partners such as Pennyroyal Healthcare Service, using CCM to help with program design. The program focuses on people managing chronic conditions such as obesity, diabetes, heart disease, and cancer. The program offers prevention and treatment options, including primary care services to help improve these conditions, and referrals to other services to help provide holistic patient care. Physicians, nurses, and health coaches work with patients to develop management care plans with achievable health goals.
  • The Williamson Health and Wellness Center in West Virginia is implementing the Quality Lives program to help improve the delivery of quality, team-based care to community members living with diabetes and heart disease. To deliver services, the program uses the CCM model; the Care Transitions model — specifically, the Care Transitions Intervention (CTI); and the Medication Management model. Examples of program activities include community events to educate about the risks of diabetes and heart disease and text message reminders to patients about medication.
  • The iCARE (improved care and provision of rural access to eliminate health disparities) project began in 2017 with funding through the South Carolina Center for Rural and Primary Healthcare and since that time has delivered care to patients in over 32 counties in the state. The project supports subspecialty clinics, such as pulmonology, endocrinology, and cardiology, that provide direct services in rural communities. Outreach specialty clinics are held several times per week or month, depending on the community, to increase local access to specialists needed to manage chronic diseases. The specialty services are provided directly in the primary care practice so that patients avoid having to travel to access specialty care.

Implementation Considerations

CCM involves changes within healthcare settings to improve the management of chronic diseases. In many healthcare settings, workflow changes and practice transformation can be difficult to achieve and may require additional resources, such as staff time, technology, and training materials. Practice transformation specialists and practice transformation coordinators are staff with specialized training to facilitate and oversee the implementation of practice transformation initiatives who work in hospitals, medical centers, and other community-based organizations that provide care to patients. Their role is focused on quality improvement and implementing changes to improve care. Organizations looking to implement CCM and other integrated models of care for patients with chronic diseases may consider whether they can hire or train existing staff to become a Practice Transformation Specialist or Practice Transformation Coordinator to direct this work.

Often, small rural clinics have more limited resources. Rural organizations may consider sharing or combining resources with other rural health centers, Federally Qualified Health Centers, or other medical settings to save costs. This could include, for example, sharing clinical information systems or sharing staff, such as a Practice Transformation Coordinator, among several clinics.

Program Clearinghouse Examples

Resources to Learn More

Chronic Illness Care Resource Library
Compilation of resources including coaching guides, toolkits, models, and assessments for leading practice transformation to improve the delivery of chronic illness care.
Organization(s): ACT Center, Kaiser Permanente Washington Health Research Institute

Tools for Data-Driven Practice Transformation
Lists healthcare assessments to help health systems implement practice transformation and quality improvement initiatives to improve care including chronic illness care.
Organization(s): ACT Center, Kaiser Permanente Washington Health Research Institute