A priori framework themes identified from CCM and ICCCF conceptual models25 27 29
| CCM model element | ICCCF building block | Service delivery strategies | A priori framework themes |
| Delivery system design | Promote continuity and coordination | Defined roles and responsibilities of team members within team.* Care appropriate to cultural background* Clinical case management for complex patients* Promotion of communication within healthcare team to coordinate patient care† Continuity through planned and proactive follow-up to support evidence-based care‡ Coordination of services across levels of healthcare and providers‡ | 1. Effective team-working to deliver continuity and coordinated proactive care. |
| Health System | Encourage quality care through leadership and incentives | Promotion of effective strategies for improvement and system change* Organisational culture and leadership support of improving quality of care‡ Incentivisation of quality care‡ Quality monitoring and improvement activities as a routine among all team members, including processes for review of significant events‡ | 2. Organisational leadership, culture and mechanisms to promote quality and safety. |
| Decision support | Organise and equip healthcare teams | Promotion of continuing professional education* Access to specialist advice* Equipped healthcare teams with necessary supplies, medical equipment, laboratory access and essential medications† Training to help promote patient self-management and support behavioural change† Implementation of ongoing use of evidence-based guidelines and diagnostic and treatment algorithms‡ Effective communication to promote information exchange and patient participation in shared decision-making in evidence-based management‡ | 3. Equipped healthcare teams to deliver evidence-based patient-centred care. |
| Self-management support | Support self-management and prevention | Proactive support for patient’s self-management and prevention efforts over time† Emphasis on central role of patient in managing care‡ Use of effective self-management strategies‡ Organisation of resources to support patient self-management and prevention‡ | 4. Empowerment and support of patients for self-management and prevention. |
| Clinical information systems | Use information systems | Monitoring of team performance* Sharing of information with patients and providers for care coordination* Collection and organisation of useful patient data† Reminder systems for providers and patients‡ Identification of subpopulations for proactive care‡ Use for individual care planning‡ | 5. Use of data collection systems to facilitate effective care and follow-up. |
| Community resources and policies | Building blocks for the community | Encouraging participation of patients in effective community programmes* Raising awareness of chronic conditions and reduce stigma† Providing complementary preventive and management services through mobilising informal network of providers, such as community health workers and volunteers† Mobilisation and coordination of local community resources to support screening, prevention and improved management of chronic conditions† Forming partnerships with community leadership and organisations‡ | 6. Community partnerships to promote awareness, mobilise resources and support health service provision. |
*Model element found in CCM only.14
†Model element found in ICCCF only.25
‡Model element found in both CCM and ICCCF.14 25
CCM, chronic care model; ICCCF, innovative care for chronic conditions framework.