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Six Components of the Chronic Care Model

Karumah / Six Components of the Chronic Care Model

Karumah uses the Chronic Care Model and Assessment of Chronic Illness Care (ACIC) which was developed by Ed Wagner et al and MacColl Institute. The Six Components to the Chronic Care Model are:

1.The Community

Encourage service users to participate in effective programs

Form partnerships with community organisations to support or develop programs

Advocate for policies to improve care

2.Health System

Visibly support improvement at all levels, starting with senior leaders

Promote effective improvement strategies aimed at comprehensive system change

Encourage open and systematic handling of problems

Provide incentives based on the quality of care

Develop agreements for care coordination

3.Delivery System Design

Define roles and distribute tasks among team members

Use planned interactions to support evidence‐based care

Provide clinical case management services for high risk service users.

Ensure regular follow‐up.

Give care that service users understand and that fits their culture

4.Decision Support

Embed evidence‐based guidelines into daily clinical practice

Integrate specialist expertise and primary care

Use proven provider education methods

Share guidelines and information with service users

5.Clinical Information Systems

Provide reminders for providers and service users

Identify relevant service users subpopulations for proactive care

Facilitate individual service users’ care planning

Share information with providers and service users

Monitor performance of team and system

6.Self-Management Support

Provide reminders for providers and service users

Identify relevant service users subpopulations for proactive care

Facilitate individual service users care planning

Share information with providers and service users

Monitor performance of team and system