Numerous interventions to improve adherence to the recommended standards have been implemented.
However, a major barrier to optimal care is a delivery system that is often fragmented, lacks clinical information capabilities, duplicates services, and is poorly designed for the coordinated delivery of chronic care. The Chronic Care Model (CCM) has been shown to be an effective framework for improving the quality of diabetes care .
Six Core Elements
The CCM includes six core elements for the provision of optimal care of patients with chronic disease:
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Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach)
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Self-management support
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Decision support (basing care on evidence-based, effective care guidelines)
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Clinical information systems (using registries that can provide patient-specific and population-based support to the care team)
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Community resources and policies (identifying or developing resources to support healthy lifestyles)Health systems (to create a quality-oriented culture)
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Redefining the roles of the health care delivery team and promoting self-management on the part of the patient are fundamental to the successful implementation of the CCM. Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients’ self-management
