The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

Ahmed, Sara; Ware, Patrick; Visca, Regina; Bareil, Celine; Chouinard, Maud-Christine; Desforges, Johanne; Finlayson, Roderick; Fortin, Martin; Gauthier, Josée; Grimard, Dominique; Guay, Maryse; Hudon, Catherine; Lalonde, Lyne; Lévesque, Lise; Michaud, Cecile; Provost, Sylvie; Sutton, Tim; Tousignant, Pierre; Travers, Stella; Ware, Mark; Gogovor, Amede

doi:10.1186/s13104-015-1514-0

Table 2 Elements of Chronic Care Model (CCM) included in each program

From: The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

CCM component	P1	P2	P3	P4	P5	P6	P7
Health system
Visibly support improvement at all levels of the organization, beginning with the senior leader					√		√
Promote effective improvement strategies aimed at comprehensive system change						√	√
Encourage open and systematic handling of errors and quality problems to improve care	√	√				√	√
Provide incentives based on quality of care
Develop agreements that facilitate care coordination within and across organizations	√	√		√	√	√	√
Delivery system design
Define roles and distribute tasks among team members	√	√	√	√	√	√	√
Use planned interactions to support evidence-based care	√	√	√	√	√	√	√
Provide clinical case management services for complex patients			√			√	√
Ensure regular follow-up by the care team	√	√	√	√	√	√	√
Give care that patients understand and that fits with their cultural background				√	√	√	√
Decision support
Embed evidence-based guidelines into daily clinical practice	√	√	√	√	√	√	√
Share evidence-based guidelines and information with patients to encourage their participation	√	√	√	√	√	√	√
Use proven provider education methods	√	√	√	√	√		√
Integrate specialist expertise and primary care	√			√	√	√	√
Clinical information systems
Provide timely reminders for providers and patients	√	√				√	√
Identify relevant subpopulations for proactive care	√	√	√			√	√
Facilitate individual patient care planning	√	√	√	√	√	√	√
Share information with patients and providers to coordinate care	√	√	√	√	√	√	√
Monitor performance of practice team and care system	√	√		√		√	√
Self-management support
Emphasize the patient’s central role in managing their health	√	√	√	√	√	√	√
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up	√	√	√	√	√	√	√
Organize internal and community resources to provide ongoing self-management support to patients	√	√	√	√		√	√
The community
Encourage patients to participate in effective community programs	√	√	√	√	√	√	√
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services		√		√	√	√	√
Advocate for policies to improve patient care	√				√		√

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ISSN: 1756-0500

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