Topic outline

  • Welcome

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    Welcome to the Implementing the Chronic Care Model for the Management of Noncommunicable diseases (NCDs) in the Primary Care Setting training course.

    This course is a collaboration between the Ministry of Health and Wellness and the Caribbean Training and Education Center for Health (C-TECH). The course is designed for health professionals involved with chronic disease management and quality of care in the primary care setting of the public health system.

    This course will introduce the Chronic Care Model developed by Edward H. Wagner and promoted by the World Health Organization (WHO). It will introduce participants to ways in which health systems can be reoriented to better manage chronic conditions such as diabetes, cardiovascular diseases, cancer and chronic obstructive pulmonary disease.

    Participants will learn practical skills in analysing and evaluating approaches and services in a variety of settings, making comparisons between them and identifying capacities and opportunities for change.

    If you have not already completed Moodle Student Support, please take some time to complete it before proceeding with this course.

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  • Module 1

    Chronic Care Model Overview

    Welcome to Module 1. In this module we will introduce you to the course and provide you with a brief overview of the current state of the healthcare system. We will also discuss non-communicable diseases (both globally and chronic disease in Jamaica, including the burden as well as policies and programmes) and introduce you to the Chronic Care Model.

    Learning Objectives

    Upon completion of this module, you will be able to:

    • Describe the development of the Chronic Care Model (CCM);
    • Identify the six components of the CCM;
    • Comprehend the assessment of chronic illness care; and
    • Practice collaborative learning and quality improvement.

  • Module 2

    Applying the Chronic Care Model (Part 1)

    Welcome to Module 2. In this module, we will introduce you to the course and provide you with a brief overview of the current state of the healthcare system. We will also discuss non-communicable diseases (both globally and chronic disease in Jamaica, including the burden as well as policies and programmes) and introduce you to the Chronic Care Model.

    The Chronic Care Model identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self- management support; delivery system design; decision support, and clinical information systems. Within each of these elements, there are specific concepts (Change Concepts) that teams use to direct their improvement efforts. Change concepts are the principles by which care redesign processes are guided.
    Source: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4. (The Chronic Care Model image first appeared in its current format in this article.)

    Learning Objectives

    Upon completion of this module, you will be able to:

    • Define health system organizations;
    • Analyze the delivery system design change concepts in the CCM;
    • Investigate decision support change concepts within the CCM;
    • Explore clinical information systems change concepts within the CCM;
    • Define the core principles of patient-centered care; and
    • Identify common barriers to implementing the CCM.

  • Module 3

    Applying the Chronic Care Model (Part 2)

    Welcome to Module 3. In this module we will continue our discussion on applying components of the Chronic Care Model (CCM). In this module, we will explore two pivotal lectures focused on the effective management of chronic conditions within the healthcare system. The first lecture, titled "Community Resources," delves into the importance of looking beyond the traditional healthcare system to harness external community resources, such as peer support groups, exercise programs, and aging service initiatives. These resources play a crucial role in enhancing patient care and reducing duplicative efforts, ultimately leading to improved patient outcomes. The second lecture, "Self-Management Support," delves into the essential aspect of empowering individuals with chronic conditions to take charge of their health on a daily basis. This lecture emphasizes collaborative care planning, goal setting, skill-building, and problem-solving, all while exploring the barriers and challenges that healthcare organizations may face in implementing the chronic care model. Together, these lectures provide valuable insights into the comprehensive approach required to effectively manage chronic conditions in the primary care setting.

    Learning Objectives

    Upon completion of this module, you will be able to:

    • Discuss community resources to support care of chronic diseases;
    • Define self-management support and its role in empowering patients to manage their chronic conditions effectively;
    • Explain the principles of motivational interviewing (MI);
    • Describe the 5 A's framework for behavior change discussions; and
    • Identify common barriers to implementing the Chronic Care Model (CCM).

  • Module 4

    Integrated Health Services Network

    Welcome to Module 4. In this module we will discuss integrated care.

    Integrated care is an approach to strengthen people-centered health systems through the promotion of the comprehensive delivery of quality services across the disease life-course. It is designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care. Integrated care should be effectively managed to ensure optimal outcomes and the appropriate use of resources based on the best available evidence. There should be feedback loops to continuously improve performance, to tackle causes of ill health and to promote well-being through intersectoral and multisectoral actions.

    Learning Objectives

    Upon completion of this module, you will be able to:

    • Define integrated care;
    • Identify the different types of integrated delivery systems; and
    • Explain the importance of an integrated care system for NCDs.