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Term Paper Example: Chronic Care Model

7 pages
1709 words
Sewanee University of the South
Type of paper: 
Term paper
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The turn of the 21st Century has been characterised by the proliferation of diabetes mellitus type 2 creating a public health concern due to the escalation to epidemic levels. According to Haas et al. (2012), the global prevalence rate of diabetes was estimated to have affected 371 million people representing 8.3% of the worlds population. Equally important is the fact that it is projected that by 2030, nearly 10% of the global population will be diagnosed with diabetes (Haas et al., 2012). A case study of the United States regarding the care accorded to diabetes patients indicates a stark contrast between urban and rural healthcare providers regarding quality and access to facilities. The existence of such health disparities in rural areas may be demonstrated by adverse health care outcomes such as higher blood pressure, worse lipid profiles and poor glycemic regulation. As a result, the rapid cycle improvement strategy is considered in the improvement of health outcomes in rural-based diabetic patients primarily through the reinforcement of patient-centred care (Stellefson, Dipnarine & Stopka, 2013). This notion is in line with global future health policies which sensitise on the need to augment the mode of delivery of primary care as the ultimate solution to serve the chronically ill population better. Research indicates that positive health outcomes have been recorded in communities where there is the adequate supply of primary care physicians, fewer new admissions and lower lengths of hospital stay thus reducing the cost of care.


The healthcare organisation intends to adopt the Chronic Care Model (CCM) which presents an extensively accepted and practice-based provision which creates assurances in the improvement of primary care settings. The core principles of the CCM models pays particular attention to the need to establish team-based care, patient empowerment, self-management and need for patient centered care (American Diabetes Association, 2016). Hence, the primary objectives of the rapid cycle improvement plan in an underserved population would comprise of quality of diabetes care in the primary care clinic, identify the risks associated with diabetes and identify evidence-based information that is to be incorporated in the protocol of diabetes management (Ali et al., 2013). Moreover, the use of information technology is essential in the development of effective communication and coordinated care for diabetic patients which in the long run creates a culture of team coordinated care. The data obtained from the electronic health record (EHR) serves the purpose of a patient registry which enables health providers to apply population-based management (Collinsworth et al., 2014). This may be achieved through data inquiries which aid in identifying patients who are most in need of an intervention.


The intervention to be adopted in this case comprises of holding regular healthcare team meetings with the aim of developing parameters of care performance measurement and improvement over the course of six months. The subjects to be included in the study would comprise of a sample data of 191 diabetic patients who have not visited the health centre for nearly six months, have an A1C of > 9% and are re-evaluated for prospective care barriers. Further, the implementation of evidence-based care would result in affordability, ease of access and attachment of each patient to a personal physician who doubles up as a team leader who ensures coordinated care across multiple specialties (Elissen et al., 2013). Equally important is the fact that the team would focus on whole person orientation where psychological and social needs are also addressed alongside medical concerns. Components of care which do not require a comprehensive medical training are delegated to non-clinical members of the healthcare team with the aid of standing orders. Activities to be conducted by such participants would include downloading glucometer data, foot examinations, conducting telephonic follow-ups and medication reconciliation (Shah, Kaselitz & Heisler, 2013). Moreover, the patients will have easy access to their health care providers through the aid of a flexible scheduling system including the ability to communicate with healthcare team members as and when required. The application of the CCM model culminates in the realisation of financial benefits such as the traditional fee-for-service reimbursements and reforms in payment systems which reward efforts directed towards achieving quality and care coordination.


An analysis plan to evaluate the outcomes of implementing the CCM model would incorporate various components such as point-of-care management, expanding the role of the clinical staff, behavioural coaching, physician leadership, team care approach and treatment intensification models. The determination of whether the objectives of the CCM model may be evaluated through the achievement on an ideal glycemic control for non-pregnant patients which ought to have declined to nearly <7% at the termination of the study, The findings obtained in regard to behavioural coaching may be embodied in the national standards of diabetes self-management education and support (DSME). The goals of such an approach include augmenting the knowledge, abilities, and proficiencies of patients which is necessary for diabetes self-care both at diagnosis and during treatment (Baumann & Dang, 2012). Adherence to the principles of DSME has been conventionally associated with positive outcomes in the health status, clinical outcomes, and improvements in the quality of life. For instance, diabetic patients who use multiple-dose insulin ought to perform self-monitoring of blood glucose as frequently as possible. The incorporation of the DSME would ensure fewer prevalence rates of asymptomatic hyperglycemia and hypoglycemia. The costs incurred during the implementation of the CCM model includes annual personnel costs of $43,400 for a full-time registered nurse, $12,000 for a full-time clinical pharmacist and $21,500 for a full-time dietician. Additionally, $3,000 was utilised in the procurement of supplies and another miscellaneous start-up cost including wages for behavioural educators. The cost per patient was estimated to be $103.50.


One of the fundamental components of the successful implementation of the CCM model is based on the incorporation of team-based care. The coordination that is established between a physician, a dietician and pharmacists ensures that the quality healthcare is accorded to diabetic patients including minimising the costs of medical care. For instance, the CCM model facilitates the integration of medical nutrition therapy (MNT) which emphasises on the need to support and promote healthy eating pattern; encourage consumption of nutrient-dense food in appropriate portions to maintain weight management goals and achieving ideal blood pressure, lipid and glycemic goals which is instrumental in addressing the complications associated with diabetes (Bauer et al., 2014). Moreover, the MNT approach deals with the nutritional needs of patients based on cultural and personal preferences, access to healthy foods and health literacy. Furthermore, the DSME structure that is unique to the CCM model is essential in the development of patient-centred, responsive and respectful individualized patient care that is aligned with the values, needs, and preferences of an individual which also guide clinical decisions. Research, organizational culture, finances, and perceptions of stakeholders are some of the elements which serve as core pillars in implementing and sustenance of the intervention. Stakeholders are crucial to the implementation of the intervention as their proficiencies based on their professionalism assist in creating the best outcomes for a patient including inspiring the release of funds based on their approval. Equally important is the fact that care is a fundamental component in any healthcare organisations and as such elements such as empathy and active listening allow team members to establish proper communication channels which supports concerted efforts during treatment of patients (Druss et al., 2012).

The effective implementation of the CCM model would necessitate the formulation of a Steering Committee is mandated with the task of developing and planning for the proposed intervention. This committee comprises of members drawn from the I.T and Finance departments, administration and the likely users from different specialties in the medical profession such as dieticians and behavioural coaches. In essence, clinicians serve the integral role of providing team leadership by spearheading activities such as patient identification mechanisms or the general documentation process (Ford, Menachemi & Phillips, 2006). The medical data that is collected over the course of the study is utilised in assessing the outcomes of the intervention. The stakeholders may be contacted by the primary caregivers by way of e-mail or telephone on a monthly basis so that such professionals may offer their much need expertise in a team care approach.



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American Diabetes Association. (2016). Standards of medical care in diabetes2016 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 34(1), 3.

Bauer, A. M., Thielke, S. M., Katon, W., Unutzer, J., & Arean, P. (2014). Aligning health information technologies with effective service delivery models to improve chronic disease care. Preventive medicine, 66, 167-172.

Baumann, L. C., & Dang, T. T. N. (2012). Helping patients with chronic conditions overcome barriers to self-care. The Nurse Practitioner, 37(3), 32-38.

Collinsworth, A., Vulimiri, M., Snead, C., & Walton, J. (2014). Community health workers in primary care practice: redesigning health care delivery systems to extend and improve diabetes care in underserved populations. Health promotion practice, 15(2_suppl), 51S-61S.

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Elissen, A. M., Steuten, L. M., Lemmens, L. C., Drewes, H. W., Lemmens, K. M., Meeuwissen, J. A., ... & Vrijhoef, H. J. (2013). Metaanalysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes. Journal of Evaluation in Clinical Practice, 19(5), 753-762.

Ford, E. W., Menachemi, N., & Phillips, M. T. (2006). Predicting the adoption of electronic health records by physicians: when will health care be paperless?. Journal of the American Medical Informatics Association, 13(1), 106-112.

Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., ... & McLaughlin, S. (2012). National standards for diabetes self-management education and support. The Diabetes Educator, 38(5), 619-629.

Shah, M., Kaselitz, E., & Heisler, M. (2013). The role of community health workers in diabetes: update on current literature. Current diabetes reports, 13(2), 163-171.

Stellefson, M., Dipnarine, K., & Stopka, C. (2013). Peer reviewed: The chronic care model and diabetes management in US primary care settings: A systematic review. Preventing chronic disease, 10.

Appendix A

Curriculum Vitae

Name: Dr. Felix Aguilar, MD, MPH, MHCM

Current Occupation: Associate Vice President/Medical Director at Blue Shield of California-Care 1st


Visionary physician leader with distinguished record of administrative, clinic...

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