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 |