Community Health Management Quiz

Chronic Care Model (CCM)

• The CCM is a model developed by Wagner and adapted by organizations like the CDC.
• It's a framework for improving chronic disease management.
• It aims to improve healthcare quality and prevent complications.
• The CCM seeks to ensure high-quality care across various illnesses, settings, and populations.
• It fosters partnerships between providers and communities.
• The CCM's goal is to improve patient health, provider satisfaction, and reduce costs.

Objectives of the Chronic Care Model

• Define the chronic condition.
• Identify the purpose of the chronic care model.
• Identify three risk factors leading to chronic disease.
• Identify the management of chronic conditions.
• Identify the elements of the model.
• Identify the application of CCM into practice.

Definition of Chronic Condition

• A chronic condition refers to any long-term health issue needing continuous self-management by the individual and regular interaction with the healthcare system.

Definition of Non-Communicable Diseases (NCDs)

• Also called chronic diseases, NCDs are typically long-lasting.
• They result from a mix of genetic, physiological, environmental, and behavioral factors (according to the WHO).

Risk Factors for Chronic Diseases

• Poor dietary habits
• Lack of physical activity
• Tobacco use
• Excessive alcohol consumption
• Aging
• Bad lifestyle

Statistics on Chronic Diseases in Jordan (2016)

• Jordan experienced 29,855 deaths in 2016.
• 76% (22,690) of these deaths were attributed to NCDs.
• In 2025, the number of NCD-related deaths is expected to rise to 29,487.
• These deaths are primarily caused by cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes.
• The risk of death from an NCD between the ages of 30 and 70 in Jordan is 20%.
• In 2010, 13% of the population had chronic diseases.
• 34% of Jordanian families had at least one member affected by a chronic disease

Chronic Diseases Worldwide Statistics (2022)

• A pie chart displays the percentage distribution of various chronic diseases.
• Information on percentages is provided for diseases like "no chronic diseases," "diabetes," "chronic lung disease," "cardiopathy," "hypertension," "cancer", "hepatic disease", and "stroke".

Definition of the Chronic Care Model (CCM)

• The CCM model is designed to improve the management of chronic diseases.
• It emphasizes patient-centered care, self-management, and integrated health care systems.

Chronic Care Model Purposes

• Enhancing Patient Self-Management: Empowering patients through education and tools to actively manage their health.
• Improving Health Outcomes: Using evidence-based systems to improve clinical results and prevent disease exacerbations.
• Reducing Healthcare Costs: Preventing complications and minimizing hospitalizations.
• Increasing Patient Satisfaction: Providing high-quality, patient-centered care.
• Strengthening Provider Support: Encouraging collaborative care teams.
• Integrating Community Resources: Partnering with community programs to enhance patient support.

Model Elements

• Community
• The health system
• Self-management support
• Delivery system design
• Decision support
• Clinical information systems

Community Resources to Meet Patient Needs

• Motivate patients to engage in impactful community programs.
• Collaborate with community organizations to establish and enhance interventions that address unmet service needs.
• Advocate for policies that prioritize improved patient care.

The Health System

• Ensure visible support for improvement initiatives.
• Promote impactful strategies for achieving comprehensive system-wide changes.
• Encourage transparent and systematic management of errors and quality concerns.
• Introduce incentives that prioritize and reward high-quality care.
• Create agreements to enhance care coordination within and across organizations.

Self-Management Support

• Highlight the patient's key role in managing their health.
• Implement effective self-management strategies.
• Organize both internal and community resources to offer continuous self-management support to patients.
• Patients make decisions with impact.
• Success of disease management is influenced by patients managing their health.

Delivery System Design

• Ensure the provision of effective, efficient clinical care.
• Clearly define roles and distribute responsibilities.
• Utilize planned interactions to facilitate evidence-based care.
• Offer clinical case management.
• Ensure consistent follow-up by the care team.
• Provide understandable care aligned with cultural values.

Decision Support

• Share evidence-based guidelines.
• Use effective methods to educate providers.
• Incorporate specialist expertise.
• Treatment decisions should be based on evidence-backed guidelines.

Clinical Information Systems

• Provide timely reminders for providers and patients.
• Support individualized care planning.
• Enable information sharing.
• Track the performance of the healthcare team and system.

Updated CCM Themes (2003)

• Patient Safety
• Cultural Competency
• Care Coordination
• Community Policies
• Case Management

Application of CCM in Practice

• National patient organizations (e.g., HCAC, JUH) applying CCM.
• National center for Diabetes (DM) example.

Article: Operationalizing the Chronic Care Model with Goal-Oriented Care

• This article discusses operationalizing CCM through goal-oriented care, focusing on chronic disease management.
• It highlights patient-centered care, self-management, and integrated healthcare systems.
• The article outlines how technology and data management help track patient progress.

Article: Results

• The article emphasizes the effectiveness of CCM combined with goal-oriented care.
• Results show improvements in patient outcomes through self-management, improved communication, utilization of technology, and patient engagement.

Conclusion

• Summarizes the key points of the model.