The Chronic Care Model


The Chronic Care Model (CCM), developed in the 1990s, is an important framework for the management of chronic disease.60-62


The model focuses on


patient-centered care, which is supported by intricate partnerships between the patient, health care providers, the community, and policy makers.63


The CCM


replaces more acute and disease-focused therapies previously used in primary care, as chronic diseases are far more complex and persistent than are acute ill- nesses. Historically, disease-focused therapies have relied heavily on physicians and were contributing to physician burnout, patient dissatisfaction, and poor health outcomes for patients when applied to chronic diseases.62 The CCM includes six components: (1) the health system or health orga- nization; (2) clinical information systems; (3) decision support; (4) delivery system design; (5) self-management support; and (6) community, which includes organizations and resources for patients (refer to Box 15.4 on page 280).60-65 The individual components are not meant to be used in isolation, and experts recommended that practitioners employ at least two or more for the best care.63 According to previous literature, the three components perceived as priorities in the primary health care setting are clinical information systems, decision support, and self-management support.63


However, which CCM components are


implemented and how they are implemented is unique to each health care facility, making it difficult to systematically determine their overall effectiveness.58,64


It is


unlikely that each component operates in isolation; rather, the components are likely synergistic. Therefore, testing the individual effects of CCM components is not recommended.58,63


Research suggests that smaller primary care practices


may be less likely to implement all components, as doing so is seen as financially challenging and labor-intensive for small clinics.58


The CCM has been shown to


improve health outcomes in people with chronic disease, with demonstrated improvements in hemoglobin A1c levels, blood pressure levels, BMI, low-density lipoprotein cholesterol levels, and treatment goals.58,65


However, research on the


model has been conducted primarily among people with type 2 diabetes and there is limited research on the effectiveness of the CCM for other chronic conditions, including obesity.63,65 The 2013 AHA/ACC/TOS guidelines propose a chronic disease management


model for the treatment of overweight and obesity (refer to Figure 15.1 on page 281).24


The model focuses on assessment by the primary care provider and possi-


ble interventions to be discussed with the client, embracing the CCM components of decision support, self-management support, and resources for patients. In light of changes in health care practices in response to the COVID-19


pandemic, a team of researchers reviewed eHealth tools that are used to support the CCM and proposed a revised CCM, called the eHealth Enhanced Chronic Care Model (eCCM).56


feedback loop when using eHealth-based interventions.56,66


feedback loop include: (1) providing health status data to patients, (2) interpret- ing the health care data and information provided to patients, (3) addressing the unique needs of the patient, (4) ensuring the patient receives the information in a timely manner, and (5) ensuring there is consistent repetition of the health care information.66


Research Gaps for the Chronic Care Model


Despite the promising research on the eCCM, there is scant research on the management of chronic conditions through eHealth and telehealth.57


A rapid CHAPTER 15: Obesity as a Chronic Disease and Its Lifelong Management 279


Their review also stressed the importance of a complete The five stages of the


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