| Tool
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 Chronic
Care Model Diabetes Collaborative
Description:
Print out your own copy of the MacColl Institute
ICIC Chronic Care Model checklist
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to download
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Determining
Needs and Setting Priorities for Systems Change
Tool:
Chronic Care Model
 Bureau
of Primary Health Care (BPHC) Diabetes Collaborative
As
your practice or organization assesses its needs and plans a strategy
for action, it will be helpful to view this respected model of care
from the Bureau
of Primary Health Care (BPHC) Diabetes Collaborative.
BPHC
has adapted materials from the MacColl Institute ICIC Chronic Care
Model to create the following simplified checklist for the core
elements of the Chronic Care Model. See right for a downloadable
version of this checklist in Adobe Acrobat format.
Questions
to ask and ANSWER as you develop components of the Chronic Care
Model for your center:
 1.
Health Systems
This applies to your CHC structure and day-to-day operations.
| Yes |
No |
Questions
to Answer: |
| |
|
Does
your current Health Care Plan (grant) include - Diabetes Care?
- Chronic Disease Management? |
| |
|
What
are your Health Care Plan goals? |
| |
|
Does
your CEO/ Medical Director understand the Model? (If no, what
are your team's plans to educate?) |
| |
|
Is
the CEO/ Medical Director committed (visit times/ scheduling,
money & resources for education, etc.) to meeting the needs
of patients with chronic illness? |
| |
|
How
can you better enlist support of the CEO/ Medical Director,
other providers and staff?
|
| |
|
Is
there currently an ACTIVE patient education and services for
your ENTIRE population? |
| |
|
What
is your current performance improvement model? (QA,QI program)
|
| |
|
»is
it actively in use?
|
| |
|
»is
there a QI team or committee?
|
| |
|
»do
they meet regularly?
|
| |
|
»does
the current program effectively improve anything?
|
| |
|
»Are
there plans to incorporate the Senior Leader report as part
of the QI meeting
|
| |
|
Outcomes, costs and satisfaction of a sample of diabetic population
are analyzed regularly (i.e. monthly) to access the performance
of the system of care for the population? |
| |
|
Does the team understand the PDSA Model well enough to teach
it to the rest of the staff? If not, what are the plans to get
that done? |
| |
|
Are there incentives for providers to support chronic illness
goals? |
2.
Decision Support
This
is about the Standards of Care developed/ adopted by your CHC to
care for DIABETIC patients that come to your center:
| Yes |
No |
Questions
to Answer: |
| |
|
Do
you have evidence based Diabetes guidelines integrated into
clinical practice? |
| |
|
Do you have clinical protocols for diabetes? |
| |
|
Are
they regularly used? |
| |
|
Is
there a method in the system for integrating clinical expertise
from generalists and specialists? |
| |
|
Does
the care team work to maximize cooperation and apply the guidelines
and protocols? |
| |
|
»If
no, is there a plan in plan to improve the cooperation and
application?
|
3. Clinical Information System
This applies to the center's IS system AND the Diabetic
Registry:
| Yes |
No |
Questions
to Answer: |
| |
|
Is
the registry developed? |
| |
|
What is the plan to include ALL of your diabetic population
in the registry?
|
| |
|
Is there a person assigned to update the registry on a regular
basis? |
| |
|
What is the method for obtaining the data to enter into the
registry?
|
| |
|
Is there a plan for reminder system for patient and team of
follow up needs? |
| |
|
Is there a plan in place for the team to regularly review data
from the registry? |
| |
|
Is
there a system in place to allow for care planning? |
4. Delivery System Design
This applies to the delivery of care provide for diabetic patients:
| Yes |
No |
Questions
to Answer: |
| |
|
Are
there visits specifically designed for Diabetic patients at
regular intervals? (As opposed to ALL acute care episodes?)
|
| |
|
Is there a method in place for the practice to anticipate problems
and provide services to maintain quality of life and function
for the patient? |
| |
|
Describe the care team of the patient with diabetes:
|
| |
|
How does the care team work together with the patient?
|
| |
|
Does the care team meet regularly to review their diabetic population
and how well the care provided is impacting the patient? |
| |
|
Is
the system designed for regular communication and follow up
with the patient? |
5.
Self- Management Support
PLEASE NOTE: self-management is NOT the TRADITIONAL approach
to education of the patient. Self-management involves methods to
make the PATIENT responsible for their disease process rather than
the provider. This sections addresses that aspect of the model:
| Yes |
No |
Questions
to Answer: |
| |
|
Does
the program you have (or are developing) EMPHASIZE the patient's
role in managing the illness? |
| |
|
Are
there educational resources available to increase patient knowledge,
confidence and skill in managing their illness? (Self-Management
materials as well as traditional educational materials?) |
| |
|
Is
there a method to ASSIST the patient in setting personal goals?
|
| |
|
»Is
there a method to document these for the patient and the
medical record? Are there methods to measure progress and
provide feedback to patients on their progress?
|
| |
|
»Are there aids & programs to assist in changing
behaviors? (smoking cessation programs, walking groups,
etc.)
|
| |
|
Are
there patient group meetings (peer support)? |
| |
|
Is there a plan to assist patients in improving communication
with providers about their healthcare? |
6.
Community Resources & Policies
This addresses the community aspects of the model - what's
available and can it be linked back to the patient:
| Yes |
No |
Questions
to Answer: |
| |
|
Have
you made contact with your local hospital to discuss the program
and how it could be mutually beneficial? |
| |
|
Do
you know what your needs are? |
| |
|
What
are the possible community resources to support diabetes care?
(neighborhood groups, church, senior centers, work sites,
other diabetes projects, etc.)
|
| |
|
List the community service agencies:
|
| |
|
Are
they accessible for the patients? |
| |
|
What are the commonalties between you and them?
|
| |
|
Have you met with them to discuss common goals? |
| |
|
What
is your plan for involving the community?
|
Developed
by Jan Wilkerson, SE Cluster Coordinator, HRSA/BPHC Diabetes Collaborative.
Reprinted
with permission.
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