- Overview
- Adult Immunizations
- Alcohol and Substance Use (SBIRT)
- Asthma
- Appropriate Use of Antibiotics for ARI
- Colorectal Cancer Screening
- Cardiovascular Disease (CVD) and Stroke Prevention
- Depression
- Diabetes in Adult Patients
- Gestational Diabetes
- Obesity
- Pediatric Immunizations
- Pneumococcal & Influenza Standing Orders
- Prevention
- Tobacco Cessation and Secondhand Smoke Exposure
CCM and PCMH Resources
This page contains resources on the Chronic Care Model (CCM) and Patient Centered Medical Home (PCMH) for self-directed practices.
The Chronic Care Model
Click on elements of the Chronic Care Model graphic below for more resources.
What will it take to improve chronic illness care?
Or, in general, to see improved health outcomes across our nation? By intuition, we know that there are two sides to the equation. In order to have improvement in health outcomes, the patient-provider interaction will need to be as productive as possible. The literature has shown us that this is achievable when those interactions take place between an engaged, motivated patient (and family) and a practice team that is prepared and skilled in delivering planned, proactive care. This is a desired state in which we all might prefer to deliver health care services—and be compensated for this level of care.
Elements of the CCM
Click on the links below for more resources.
- Community Resources and Policies
- Health Systems Organization of Healthcare
- Self-Management Support
- Delivery System Design
- Decision Support
- Clinical Information Systems
- Informed, Activated Patient
- Prepared, Proactive Practice Team
For productive interactions to be the best that they can be, fostering the best possible health outcomes, many things need to align on both sides of the equation. An in depth survey of the literature provided an evidence base for the development of the Chronic Care Model, first published in 1998. This model details the specifics for the elements necessary to optimize this equation.
Here at CCGC and in the IPIP program, we recognize that work toward implementing the CCM alone, while admirable, is arduous at best. Implementation of the CCM, in pursuit of achieving improved health outcomes and decreases in health care costs, cannot be successfully accomplished in a vacuum. Many of the pieces required to achieve this end lie outside the control or resource of the individual primary care physician and practice. The work of CCGC, at many levels, helps to pull together these pieces for the primary care practice that is ready to engage in the task of working toward improved health outcomes with its patients.
Additional Information
For questions and additional information, please contact Allyson Gottsman at (720) 297-1681.
