Table 1 Elements of the Collaborative Chronic Care Model (CCM), adapted from [7]
CCM element | Definition | Example |
|---|---|---|
Work role redesign | Providing care that anticipates patients’ needs and preferences through redesigning processes within an interdisciplinary team structure | Establishing a care manager role to conduct phone-based assessments with patients, place reminder calls, and follow up after appointments to ensure continuity of care |
Patient self-management support | Enhancing patients’ self-management skills to help them work toward wellness outside of treatment sessions | Supporting self-management and coping skills for patients to use between appointments (e.g., via homework and mobile apps) |
Provider decision support | Ensuring that the treatment team’s providers have access to needed clinical expertise | Making available treatment manuals, medication algorithms, and streamlined access to specialty consultation (in cases where there is a concern outside of their area of expertise) |
Clinical information systems | Using electronic/automated mechanisms to enhance evaluation and coordination of care, with an emphasis on caring for patient populations or panels | Establishing a registry or panel of patients for whom the treatment team is responsible, through which the team can track outcomes, including measurement-based care, across the whole team’s caseload to enable targeted feedback to providers |
Linkages to community resources | Facilitated or systematic relationships with entities outside of the immediate treatment setting to support care delivery and community integration | Routinely using local community resources or web-based peer support services located outside of the clinical setting (e.g., recreational groups, housing assistance programs, transportation services, Alcoholics Anonymous, Depression and Bipolar Support Alliance) |
Organizational/leadership support | Providing resources and support to the treatment teams from various levels within the organization, including executive level leaders as well as more direct line supervisors and managers in mental health specialty care services | Providing dedicated time to attend treatment team meetings and incentivizing attendance; ensuring that teams are fully staffed and have the support needed to enact the other CCM elements |