Chronic Care Management: Its Definition and Meaning for Diabetic Patients

Chronic care management, or the Chronic Care Model (CCM), was composed by Ed Wagner and colleagues, according to the Agency for Healthcare Research and Quality, a division of the U.S. Department of Health and Human Services. Chronic care management, by definition, is "a comprehensive strategy for improving care for people with chronic illness." It gives patients much more than they receive in the Acute Care Model, where they only go to a clinic, or to a private physician, when they are experiencing health crises. The Chronic Care Model includes "one or more of 6 core elements:

  • An "organizational environment"(doctor's office/clinic) that puts a priority on healthcare leadership,
  • Links to "community resources" that are "cost-effective," even though these resources may be outside of the healthcare organization, such as links to "nutrition counseling, support groups and patient-data registries,"
  • An emphasis on "patient empowerment and self-management" of the chronic illnesses,
  • A "delivery system" that "coordinates actions of multiple caregivers," like doctors, nurse practitioners, educational group leaders and supportive family members, Computer tracking systems that contain patient information and intervention outcomes within "registries, flow sheets and assessment tools."
  • The use of the above-described tracking systems with the goal of contacting patients regarding "proactive care (seeing the doctor before a crisis), reminders(times and circumstances for taking prescribed medications) and treatment plans," so that these patients may be successful at self-care.
  • As regards the management of diabetes, a chronic condition which affects (2012 statistics) more than 29.1 million, or 9.3% of the U.S. population, The American Diabetes Association declares that 25.9% of our residents over the age of 65, or 11. 8 million seniors, struggle with this disease.

For these reasons, researchers at the University of Pittsburgh Medical Center (UPMC) developed a Chronic Care Model for treating diabetes "that stresses prevention":

  • Primary-care physicians received management guidelines "based on scientific evidence,"

  • Physicians, nurses and/or other "educators" took the time to give patients on-site, detailed information about the disease and how to manage it,

  • Physicians received a "variety of computerized data" to better track how well their patients were applying their diabetes education. This data included regular measures of blood glucose, LDL (bad) cholesterol and kidney functions.

The results of several studies which employed this Chronic Care Model for diabetes showed "improved blood glucose control, lower LDL levels, improvements in HDL (good) cholesterol, higher rates of blood glucose self-monitoring (checking one's own blood sugar) and higher empowerment scores." Empowerment numbers showed "how much control people felt they had over their health."

Contact us to receive cutting-edge information about how you, the physician or clinic manager, can easily learn to empower your patients to work along with you to better-manage their diabetes.

Chronic Care Management: Its Definition and Meaning for Diabetic Patients

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