One collaborative practice model used in healthcare is the chronic care model (CCM) which has been successful in addressing preventative care and disease management. Within the CCM model, there is an emphasis on three elements impacting chronic care consisting of the community with its rich resources, policies and payment structures associated with the healthcare system, and the provider practice/organization (Fisher & Dickinson, 2014). The CCM model focuses on patients taking an active role in self-management and taking a hands-on approach to chronic care execution. The CCM is useful and effective because it can be applied to a variety of chronic illnesses, healthcare settings and target populations which leads to healthier patients, greater efficiencies/resource utilization and greater care deliveries (Group Health Research Institute, 2020). Additionally, under this model healthcare professionals across the board can share pertinent information, lessons learned, experiences and ensure cross-flow of this information to help address targeted populations which drives improved care overall. For instance, under the CCM model it enables psychologists the ability to make contributions with respect to clinical services, preventative and behavioral programs, and psychosocial programs to help with managing chronic disease in patient population groups (Fisher & Dickinson, 2014). CCM models have created partnerships with healthcare systems and the communities and have been helpful in providing care for people with diabetes as another example. Evidence supported by 16 studies showed CCM approaches were effective in addressing diabetes in the primary care settings within the US which enabled healthcare leaders to initiate system-level reorganizations, generate disease registries and utilize electronic medical records to create patient-centered goals, track progress, and point out any lapses in care (Stellefson et al., 2013). Lastly, the CCM model helps primary care physicians to deliver effective care backed by evidence and helps provide education to patients in order to improve health outcomes. In conclusion, all of the elements within the CCM model help to create a more effective provider-patient relationship; ultimately creating a healthier outcome for patients.
Fisher, L., & Dickinson, W. P. (2014). Psychology and primary care: New collaborations for providing effective care for adults with chronic health conditions. American Psychologist, 69(4), 355–363.
Group Health Research Institute. (2020). The chronic care model. Retrieved December 20, 2020, from http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18
Stellefson M, Dipnarine K, Stopka, C. (2013, March 4). The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. Prev Chronic Dis 2013;10:120180. DOI: http://dx.doi.org/10.5888/pcd10.120180
The patient-centered medical home (PCMH) model focuses on improving how primary care is delivered (Agency for Healthcare Research and Quality, n.d.). There are five functions of a PCMH:
- Comprehensive care-ensuring that the care is all encompassing and offers a multidisciplinary approach to providing physical and mental health care
- Patient centered-this is the crux of the model. It ensures patients are seen as one whole entity and their unique needs are factored into their care. In addition, the wishes of the patient and family are incorporated into the care plan.
- Coordinated care-there are many moving parts in a patient’s care and this must all be coordinated so that a smooth outcome is reached. Coordinating care across sites, from hospital to home, hospital to hospital, etc., requires time and attention to help the patient receive quality care and good outcomes.
- Accessible services-care that is inaccessible is nonexistent. If a patient does not have access to timely care, poor outcomes can occur. Also, if patients are not educated on how to access care, it can be detrimental. This may be in the form of same day visits, urgent care, telephone triage, portal access, etc. Educating patients on how and when to seek care as well as having available access is an important component of this model.
- Quality and safety-by using tools to measure and ensure quality, care can consistently be improved. Utilization of evidence based medicine, including patients/families in decision making, assessing patient satisfaction and using models to improve care are all important.
When I was a director of nursing back in 2001, there was a national campaign to “redesign” health care. It consisted of many of the PCMH components and I have no doubt that it was the predecessor for the PCMH model as that term did not yet exist. Community health centers (CHCs) all over the country attended seminars and trainings to improve how they delivered care and put the patient at the center of it all. At my CHC (which was the first CHC in the nation), we began with the ‘huddle’ concept (which was new back then) and we all met the morning of each clinic. We also, created “teams” that consisted of the physician/NP, RN and medical assistant. Corso and Gage (2016) find that teams are essential for patient management. We reviewed all patient charts for the following day. We made sure radiology reports were available for the visit, had the front desk be proactive with any insurance coverage issues, made sure we had a paper chart for each patient (as that was a huge deal before the EMR), became proactive with prior authorizations, etc. It was our first multidisciplinary approach as it included nurses, medical assistants, front desk staff, clinical providers, medical records, laboratory staff, etc. At the end of the project, all CHCs who participated went to Philadelphia and used poster boards to display their program and how it contributed to improved quality outcomes for the patient. It was a great opportunity to share ideas, learn a completely new way of doing things and commend each other for the hard work. It was a pleasure just to be in the presence of others who understood what it meant to provide care in a community setting (most of which were under served).
Again, I was able to link this week’s discussion to my father, as he admitted to MGH last week. They had planned to discharge him home the day of the storm but I was adamant that it did not happen. The social worker said they could have “The Ride” bring him home. However, the issue was not about him just getting home. It was about me as his daughter (and a nurse) understanding that the biggest hurdle is not just getting him from point A to point B. There is much that goes into the discharge process; new medications that need to be picked up from the neighborhood pharmacy, making sure he knows what pills to take that night, getting him settled back into a home that he has not been in for 1 week and being sure he has food since he has not been able to shop while admitted. Roux (2019, p. 1) confirms that medication management “can become particularly tricky in the context involving a return home after a hospital stay and changes in the usual prescription, especially for older adults undergoing polypharmacy.”When I talked to the nurse, she totally got it. She said there was no sense in having him leave that day if there was no one who could follow up on these things. She reached out to his PCP, the ID specialist and his cardiac team. Because of this collaboration, they postponed the discharge to the following day. And even with that (which we were grateful for) there were so many bumps in getting his medication, but as I was there, I was able to help the hospital get him what he needed. There is just no way my father would have been able to navigate any of that on his own. That is why it is important for the care team to have open communication with the patient and family members so that everyone is on board.
Agency for Healthcare Research and Quality. (n.d.) Defining the PCMH.
Corso, K. A., & Gage, D. (2016). Nurses and Psychologists Advancing the Patient-Centered Medical Home Model. Nursing Administration Quarterly, 40(3), 192–201.
Roux, P., Verloo, H., Santiago-Delefosse, M., & Pereira, F. (2019). The spatial dimensions of medication management by home-dwelling older adults after hospital discharge. Health and Place, 60. https://doi-org.ezproxy.snhu.edu/10.1016/j.healthplace.2019.102230