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Table 1 Core elements of the Collaborative Chronic Care Model (CCM) (Bodenheimer et al. 2002a, b; Coleman et al. 2009; Tsai et al. 2005; Bauer et al. 2016)

From: Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders

Core element

Definition

Work role redesign

Structuring care tasks of multiple clinical staff in relation to one another, such that patient needs are collaboratively anticipated and met in a timely manner

Patient self-management support

Strengthening patient’s ability to effectively contribute to his/her own wellbeing even during times when he/she is not in direct contact with care providers

Provider decision support

Furnishing relevant information to care providers about available services, treatments, and expertise, to help them best address patient’s care needs

Clinical information systems

Activating feedback systems to share data and monitor both how care is being delivered and how patient is responding

Linkages to community resources

Connecting patient to care resources beyond those available from his/her main clinical setting

Organizational / Leadership support

Championing of clinic’s change efforts toward more CCM-oriented care (i.e., care exhibiting core CCM elements) by clinic’s organizational leaders