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Applying the Chronic Care Model (Part 1)

Site: Caribbean Health E-Learning Portal
Course: Chronic Care Model
Book: Applying the Chronic Care Model (Part 1)
Printed by: Guest user
Date: Sunday, 20 September 2026, 9:24 PM

Table of contents

1. Reading: Module 1 Recap (5 minutes)

To briefly recap what was covered in the previous module, Health systems encompass all institutions, individuals, and efforts primarily dedicated to enhancing health (WHO, 2000). They are designed to enhance people's health and well-being, meet expectations, and offer protection against health-related costs. Presently, healthcare systems face significant systemic challenges, including inadequate performance, access barriers, subpar quality, inefficient use, high costs, and low satisfaction. The primary chronic conditions causing premature mortality and disability are cardiovascular diseases (hypertension), cancers, and diabetes.

The major contributors to chronic diseases are unhealthy diet, physical inactivity, and tobacco use. According to a recent WHO report, eliminating these risk factors could prevent at least 80% of heart disease, stroke, and type 2 diabetes and over 40% of cancer (source: Preventing Chronic Diseases: a vital investment, 2005). WHO identifies four primary types of chronic diseases: cardiovascular diseases (e.g., heart attacks, stroke), cancer, chronic respiratory diseases (e.g., chronic obstructed pulmonary disease, asthma), and diabetes (Alwan, 2011). About 80% of chronic disease deaths occur in low- and middle-income countries.

Cardiovascular diseases are the leading cause of mortality in developing countries. In Jamaica, hypertension and diabetes are the top chronic disorders among the general population and significant risk factors for conditions such as cerebrovascular disease (stroke) and coronary heart disease. One in three Jamaicans has hypertension, one in eight is living with diabetes, and one in two is overweight or obese. Nearly 4 out of 5 individuals succumb to NCDs. The Chronic Care Model (CCM) serves as a pivotal framework for healthcare innovation.

This model identifies crucial elements of a healthcare system that promote high-quality care. It posits that favorable outcomes (clinical, satisfaction, cost, and function) stem from productive interactions. To facilitate such interactions, the system must develop four areas at the practice level (illustrated in the middle): self-management support (assisting patients in living with their conditions), delivery system design (defining the healthcare team and patient interactions), decision support (identifying optimal care and ensuring consistent implementation), and clinical information systems (capturing and utilizing critical clinical information). These aspects reside within a healthcare system, with broader organizational aspects influencing clinical care. The healthcare system exists within a larger community, where resources and policies also shape the care that can be provided. Notably, self-management support is positioned on the edge between the health system and the community, reflecting the visibility of patient-centric care. The Expanded CCM underscores health promotion for individuals and communities to prevent and manage chronic diseases, recognizing the role of social determinants of health in overall well-being.
Sources:

Alwan A, Maclean DR, Riley LM, d'Espaignet ET, Mathers CD, Stevens GA, Bettcher D. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. Lancet. 2010 Nov 27;376(9755):1861-8. doi: 10.1016/S0140-6736(10)61853-3. Epub 2010 Nov 10. PMID: 21074258.

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.)

2. Video: Applying Components of the Chronic Care Model (2 minutes)

In this first video lecture, we will continue our discussion on the 6 essential elements of a health care system.

Downloads: Transcript

3. Video: Health System Organization (5 minutes)

In this brief video lecture we will discuss the first element of the Chronic Care Model – the health system, in which we want to establish a health system that prioritizes safe and superior care. The business plan of this system underscores a dedicated implementation of the CCM throughout. Clinician leaders play an active and visible role within the team, advocating for improvement at every organizational level. The emphasis is on fostering effective improvement strategies that drive extensive system-wide changes. Encouragement is given to openly and systematically address errors and quality issues, seeking to enhance the quality of care. Incentives are designed based on the quality of care, and agreements are developed to streamline care coordination within and across organizations.

Downloads: Transcript

4. Video: Delivery System Design (5 minutes)

This next short video lecture focuses on the delivery system design, which ensures efficient and effective care, along with self-management support. Scheduled, proactive visits that align with patient goals assist in maintaining optimal health and aid health systems in resource management. These visits often involve a collaborative effort from various team members. Key strategies include defining roles and allocating tasks within the team, utilizing planned interactions to support evidence-based care, offering clinical case management for complex patients, ensuring consistent follow-up by the care team, and delivering care that aligns with patients' cultural background and is easily comprehensible to them.

Downloads: Transcript

5. Video: Decision Support (2 minutes)

Next, we will discuss decision support in the Chronic Care Model, which helps to aligns care with both scientific data and patient preferences. Clinicians should have easy access to up-to-date, evidence-based guidelines for managing various chronic conditions. Continuous educational outreach to clinicians reinforces the utilization of these established standards in their daily clinical practice. Key strategies include integrating evidence-based guidelines into routine clinical procedures, sharing this information with patients to foster their active involvement, employing effective provider education methods, and seamlessly integrating specialist expertise with primary care.

Downloads: Transcript

6. Video: Clinical Information System (4 minutes)

Next, we want to incorporate Clinical Information Systems to streamline and enhance care for chronic conditions. Health systems leverage technology to create a comprehensive patient registry for a specific chronic disease, enabling efficient monitoring of patient health status and minimizing complications. Key strategies encompass sending timely reminders to both providers and patients, pinpointing relevant subpopulations for proactive care, facilitating personalized patient care planning, promoting coordinated care by sharing information with patients and providers, and monitoring the performance of the practice team and care system.

Downloads: Transcript

7. Video: Patient-Centered Care (2 minutes)

Patient-centered care is a fundamental component of the Chronic Care Model and plays a critical role in improving the management of chronic conditions. This next video lecture will highlight components of patient-centered care.

Downloads: Transcript

8. Reading: Community Resources (5 minutes)

Community Resources ranging from educational institutions and government agencies to nonprofits and faith-based organizations play a vital role in bolstering health systems efforts, support and engage chronically ill patients actively. It is important to:

  • Encourage patient involvement in effective community programs.
  • Foster partnerships with community organizations to support and develop interventions addressing service gaps.
  • Advocate for policies that enhance patient care.

Numerous valuable resources and services, such as peer support groups, exercise programs, and various aging services programs, exist outside typical medical systems. It's crucial for care teams, including physicians, to educate and motivate their patients to engage in beneficial community programs. Additionally, care teams should explore partnerships with community organizations to bridge gaps in much-needed services. Examples of community resources in Jamaica include the National Health Fund, Jamaica Moves Program, the PATH program for relief and the Caribbean Community of Retired Persons.

Take a moment to think about the following self-reflective questions:

  • How might you use community resources in your role of providing patient care?
  • What might hold a team back from using these resources?
  • What has worked well for you in the past?
  • Are there any recommendations to improve the support provided?

9. Video: Barriers to Implementing the Chronic Care Model (2 minutes)

Implementing the Chronic Care Model, which is designed to improve the management of chronic conditions and enhance overall patient care, can face several common barriers. This next video will highlight some of those common barriers.

Downloads: Transcript

10. Module Summary

Congratulations on completing module 2 of the course. In this module you learned how to apply specific components of the chronic care model to your health care system setting. The CCM includes six essential elements of a health care system that when integrated encourage high-quality chronic disease care:

  1. Health System or Health Organization
  2. Clinical Information Systems
  3. Delivery System Design
  4. Decision Support
  5. Self-management Support
  6. Community Resources

In this module we focused on the first 4 elements, which address practice strategies.

12. Activities: Module 2

Thank you for completing the module. Next, please complete the module 2 quiz. We have also included an optional discussion forum, if you would like to participate.