Abstract
To address inadequacies in the management of chronic illness, the chronic care model (CCM) was developed to transform primary care practices so that they could initiate and sustain improvement in chronic care. The CCM consists of six components—community resources, health system policies, decision support, delivery system design, clinical information systems, and self-management support. This chapter describes these components and summarizes evidence supporting their efficacy. The chapter then proposes a broader model—the 10 Building Blocks of High-Performing Primary Care—that helps primary care practices make the changes necessary to implement the CCM components.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Abbreviations
- CCM:
-
Chronic care model
- EMR:
-
Electronic medical record
- A1C:
-
Hemoglobin A1c
- NCQA:
-
National Committee on Quality Assurance
- PCMH:
-
Patient-centered medical home
- RN:
-
Registered nurse
- T2D:
-
Type-2 diabetes
References
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness, parts 1 and 2. JAMA. 2002;288:1775–9, 1909–14.
Centers for Disease Control and Prevention (CDC). Vital signs: prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. MMWR Morb Mortal Wkly Rep. 2011;60(4):103–8.
Centers for Disease Control and Prevention (CDC). Vital signs: prevalence, treatment, and control of high levels of low-density lipoprotein cholesterol—United States, 1999–2002 and 2005–2008. MMWR Morb Mortal Wkly Rep. 2011;60(4):109–14.
Casagrande SS, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care. 2013;36:2271–9.
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–75.
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20:64–78.
O’Connor PJ, Sperl-Hillen JM, Rush WA, et al. Impact of electronic health record clinical decision support on diabetes care: a randomized trial. Ann Fam Med. 2011;9:12–21.
Schedlbauer A, Prasad V, Mulvaney C, Phansalkar S, Stanton W, Lip B, et al. What evidence supports the use of computerized alerts and prompts to impove clinicians’ prescribing behavior? J Am Med Inform Assoc. 2009;16:531–8.
van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138–47.
Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:E26.
Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999;22:2011–7.
Greenfield S, Kaplan SH, Ware JE, Yano EM, Frank HJL. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.
Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, vonKorff M. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med. 2005;11(Suppl 1):s7–15.
Renders CM, Valk GD, Griffin SJ, Wagner EH, van Eijk JTM, Assendelft WJJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings. Diabetes Care. 2001;24:1821–33.
Bodenheimer T. A 63-year-old man with multiple cardiovascular risk factors and poor adherence to treatment plans. JAMA. 2007;298:2048–55.
Griffin S, Kinmonth AL. Diabetes care: the effectiveness of systems for routine surveillance for people with diabetes. Cochrane Database Syst Rev. 2000;(2):CD000541.
Stroebel RJ, Scheitel SM, Fitz JS, et al. A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. Jt Comm J Qual Improv. 2002;28:441–50.
Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff. 2009;28:75–85.
Norris SL, Engelgau MM, Narayan KMV. Effectiveness of self-management training in type 2 diabetes. Diabetes Care. 2001;24:561–87.
Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer T. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med. 2013;11:137–44.
Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illness. Am J Manag Care. 2005;11:478–88.
Parchman ML, Zeber JE, Romero RR, Pugh JA. Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study. Med Care. 2007;45:1129–34.
Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12:166–71.
Willard R, Bodenheimer T. The building blocks of high-performing primary care: lessons from the field. California HealthCare Foundation, 2012.
Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK. Effects of quality improvement strategies for type 2 diabetes on glycemic control. JAMA. 2006;296:427–40.
Chen EH, Bodenheimer T. Improving population health through team-based panel management. Arch Intern Med. 2011;171:1558–9.
Bennett HD, Coleman EA, Parry C, Bodenheimer T, Chen EH. Health coaching for patients. Fam Pract Manag. 2010;17:24–9.
Bodenheimer T, Berry-Millett R. Care management for patients with complex healthcare needs. Robert Wood Johnson Foundation, 2009.
Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3:159–66.
Naik AD, Palmer N, Petersen NJ, Street RL Jr, Rao R, Suarez-Almazor M, Haidet P. Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med. 2011;171:453–9.
Geiger HJ. The first community health centers: a model of enduring value. J Ambul Care Manage. 2005;28:313–20.
Wiggins N. Popular education for health promotion and community empowerment: a review of the literature. Health Promot Int. 2011;27:356–71.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2016 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Bodenheimer, T., Willard-Grace, R. (2016). The Chronic Care Model and the Transformation of Primary Care. In: Mechanick, J., Kushner, R. (eds) Lifestyle Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-24687-1_10
Download citation
DOI: https://doi.org/10.1007/978-3-319-24687-1_10
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-24685-7
Online ISBN: 978-3-319-24687-1
eBook Packages: MedicineMedicine (R0)