Table 2 Summary of emergent themes from interview data by each core Collaborative Chronic Care Model (CCM) element
Core CCM element | Summary of emergent themes from interview data |
|---|---|
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) | Coordination challenges among organizations involved in veterans’ reentry – e.g., addressing mental health and substance use disorder needs while meeting legal requirements |
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) | Veterans’ fear of reentering society – e.g., their ability to get housing, avoid substance use relapse, and address mental health symptoms |
Provider decision support (Furnishing relevant information to care providers about available services, treatments, and expertise, to help them best address patient’s care needs) | Uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready/willing to receive services |
Clinical information systems (Activating feedback systems to share data and monitor both how care is being delivered and how patient is responding) | Lapses in mental health or substance use disorder medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records |
Linkages to community resources (Connecting patient to care resources beyond those available from his/her main clinical setting) | Inconsistent awareness of existing services and resources available across a disparate reentry system |
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) | Reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize mental health and substance use disorder needs |