Chronic Care Model





Chronic Care Model

  1. Lunch and Learn – The Chronic Care Model and how it relates to Patient Centered Medical Home (


This video is an Envision NM (New Mexico) Webinar Conference that features a number of experts and Envision representatives. The list of speakers and attendees includes the Envision NM director, a pediatrician, a systems analyst with Envision NM and medical practitioners.

The video starts with the introduction of the different speakers, presenters and attendees at the webinar. The speakers come from different medical backgrounds but most of them work with Envision New Mexico. Some of the speakers do not have any medical backgrounds but are involved in some projects with Envision. After the introduction, the host explains the rules and format of the conference along with a few issues concerning keyboard shortcuts that can make things easier for the conference attendees.

The first speaker in the video is Dr. Darcie Marcus a family medical physician. According to the video, Dr. Marcus trained at the University of New Mexico and then proceeded to work in the same city. Dr. Marcus discusses the objectives of the Patient Centre and Medical Home. To answer the questions, the speaker uses the key words why, what, who, where and when. Dr. Marcus starts by explaining the background behind the Patient Centre Medical Home program. She explains that patients with chronic illnesses require attention and care that can take up as much as 22.6 hours every day. The Patient Centre Medical Home program presents practitioners with a model that can help them provide the critical care that a patient needs without having to cut down to the essentials of the health services. Along with helping deal with the hours, the model also helps solve the question of payment for the health services by making it possible for the practitioners to provide care for their patients without losing money through failed payments. Dr. Marcus outlines the fact that experts need to do more to improve the cost and quality of medical care for patients with chronic illnesses.

After explaining the reasons behind the Patient Centre Medical Home (PCMH) program, Dr. Marcus then covers the subject’s history. She explains that PCMH started with pediatrics in the 1960s to deal with children with special needs. In the 1990s, the chronic cure model followed a period of dormancy. This model entailed community participation in the process. In 2007, four medical organizations came together to develop the key principles of PCMH. The government first recognized PCMH practice in 2008.

Dr. Marcus then covers the joint principles of PCMH. She outlines seven main principles surrounding the program. One of the key principles is that the patient still requires a physician or medical expert with them. Secondly, the person dealing with the patient needs to have help from another expert. The program’s third principle is whole person orientation. This means that practitioners need to deal with other issues concerning their patients such as their lifestyles, diets and daily activities for the system to work. The fourth key principle is that the care should be coordinated and integrated. The last three principles of the program deal with safety, quality and payment.

The next part of the video sees the speaker distinguish between regular medical care and PCMH. She reveals that there are key differences between the two in terms of the way that physicians interact with patients, the areas that they focus on and the advantages and disadvantages that each type of care provides.

Dr. Marcus divides the PCMH system into three tiers, each of which involves dealing with the patient in a different way. In the first tier, patients profit from self-care. The best way to handle them is to create a system that allows them ease of access to the physician’s services. This could be achieved by scheduling regular appointments with the physician or an assistant and having regular follow-ups through phone calls. The second tier sees patients receive more attention as they with the chronic disease that they suffer from. This means spending more time with the physician and work carried out in self-help groups. Third tier is crucial to PCMH and is not found in normal patient care systems.


The video features a webinar (web conference) from Envision New Mexico in which a number of experts discuss the Patient Centre Medical Home program. The PCMH program is a model that makes it possible for people with chronic illnesses to get quality treatment while at home to cut down on the costs of medical care. Dr. Darcie Marcus outlines that proper care for people with chronic illnesses requires the physician to tend to the patient for as many as 22.6 hours a day. However, since that is not feasible, most practitioners have to cut down on the care that the give to their patients, minimizing it to the essentials. Through the PCMH program, patients can get all the care that they need without having to spend most of their day with a doctor or incur hefty medical fees.

The PCMH started in the 1960s through an initiative by several pediatricians. Following some dormancy in the program’s development, a model for chronic cure was developed in the 1990s. It was in 2008 that the authorities started to recognize the PCMH program. A number of principles and benefits help to differentiate the PCMH program from regular care. For instance, though the patient still requires contact with a medical professional, the program allows the patient to receive this attention while at home. Additionally, the PCMH program involves all aspects of the patient’s life including their diet, lifestyle and daily activities.

  1. Meeting the challenge faced by long-term conditions – Future of health 2013 (


This video clip starts with Sir Chantler, chair of UCL Partners introducing Dr. Wagner. Dr. Wagner is the keynote speaker in the session covered by the video. He played a key role in introducing the Chronic Care Model, which caters for people dealing with long-term diseases. Through the model, people suffering from long-term illnesses are able to get special attention and care that fits their needs. Some of the health services are provided to the patients while they are at home, making it easier and more practical for them.

Dr. Wagner starts by explaining the background behind the Chronic Care Model. He outlines that the development of the program involved both patients and physicians as both parties worked together to try to figure out the best ways of helping the patients deal with their diseases and the outcomes that are best for them. By understanding the needs of patients, then physicians would be able to tune their services towards meeting those requests. This would then make it possible for services, policies and equipment to satisfy patient needs.

A key part of the program involves identifying the things that patients of long-term diseases need to maximize the outcomes of the health services. Dr. Wagner outlined several priorities that form the basis for the Chronic Care Model. Among the key priorities that Dr. Wagner identifies, is the patient’s need to become a competent manager of his or her own welfare. The speaker also outlined the need for various kinds of interventions that can help the patients control the conditions of the patients along with proper preventive care.

Dr. Wagner also explains the needs that the Chronic Care Model helps to meet. These needs include planned proactive care and organized follow-ups. Meeting these needs along with the aforementioned priorities increases the likelihood of the physician achieving success with his or her treatment. For some patients, there is a need for effective primary care in which the physician has a personal understanding of the patient and his or her condition. This calls for the integration of primary health, social health and welfare services.

Dr. Wagner then discusses the issue of care coordination for patients with long-term illnesses. He describes care coordination as the integration of activities related to patient care between several participants involved in the process to make sure that the required health services are delivered satisfactorily. Through these activities, the health services provided to the patients becomes seamless even as they move through different locations and deal with a large number of practitioners. Most parties involved in coordinated care take four major steps to guarantee the success of the program. Firstly, they made sure that there was accountability in the process. They also built relationships with patients so that they can have a rapport with them. Thirdly, they ensured that there was sharing of information between parties caring for the patient. Lastly, the parties make sure that there is proper patient support even as they switch between different providers.

Dr. Wagner then covers care management. According to the speaker, care management works better if the manager is a key member of the team that is taking care of the patient. The manager may be involved in key processes related to the treatment of the patients such as suggesting medication. The last thing that Dr. Wagner mentions on care integration is the need for greater cooperation between primary and special care. In addition to this, integrated care works best when experts dealing with a patient are in constant communication as they share opinions and ideas to prevent costly mistakes and ensure that the patient receives excellent services.

The next speaker in the video clip is Dr. Martin McShane. In his presentation, Dr. McShane discusses the future of health care. Dr. McShane states that the times are changing steadily with technology changing the way that the world operates as well as the manner in which people interact. Another change affecting health care relates to the diseases that physicians are now dealing with. Dr. McShane outlines the fact that more and more people are contracting lifestyle diseases such as diabetes, heart disease and arthritis. With the changing circumstances, Dr. McShane argues that there is a flaw in the system in that the experts designed it to fit the care they wanted to provide as opposed to the health services that the patients needed.

Dr. McShane then introduces the house of care model, which he states is a system that helps to construct a system and support interaction between people. The model acknowledges the complex nature of the system and the impossibility of having a single way of providing quality health services. Using the house as a metaphor for the entire system, the speaker explains that there is a need for two strong pillars to make person centered coordinated care possible. The first pillar sees the system give people and their physicians as much control, as they desire. The second pillar is professional cooperation. It is important for all professionals in the system to coordinate their work for the sake of their patients’ needs.

The third speaker in the video is Jeremy Taylor. Taylor focuses his presentation on Dr. McShane’s house of care metaphor. Taylor reiterates of the house of care system because it emphasizes the patient’s needs over the convenience of the physicians and experts or the protocols in the system. Taylor outlines three things that should happen to make the house of care possible. The first issue concerns permission to plan for the development of the system. The second thing needed is a drive to create a way of treating people outside the basic hospital service, while catering for all of their medical needs. Thirdly, establishment of the house of care system requires the system to redefine what a patient is. Taylor’s presentation is followed by a brief session in which the attendees ask the presenters several questions and raise issues for discussion.


This video features Dr. Ed Wagner, Dr. McShane and Jeremy Taylor as they make presentations regarding quality patient care and relating to the Chronic Care Model. The first speaker in the forum is Dr. Ed Wagner, who covers the background of the Chronic Care Model along with its main details. The speaker explains that the model focuses on the needs of the patient along with the ways of maximizing the outcomes of the treatment. Two key aspects of the Chronic Care Model that Dr. Wagner covers are care management and care coordination. In care management, Dr. Wagner explains that the use of a manager in overlooking the care of a patient can help improve the efficiency of the team. On care coordination, Dr. Wagner explains that the integration of health care activities between participants involved in the process helps to ensure that the services are satisfactory.

The video clip also features Dr. McShane who discusses the house of care model that he argues can help solve many of the world’s future health problems by increasing the quality of the health services while reducing the cost. The house of care model emphasizes the interaction between people in the system including the patients, physicians and community members. The last speaker in the video clip was Jeremy Taylor. In his presentation, Taylor outlined the factors needed to make the house of care model work. The three factors include permission to plan, redefining the patient and a drive to make it possible for physicians to care for patients who are at home.

  1. Dr. Ed Wagner – Better care for chronically ill people (


Dr. Ed Wagner is the speaker in this video as he makes a presentation at the Australasian Long-term Health Conditions Conference. Dr. Wagner starts by explaining that the population of people with chronic illnesses is growing. Part of the reason for this increase is the improvement in medical care, which has made it possible for people to live longer with the illnesses. Additionally, a large number of the population in developed states is aging. Dr. Wagner argues that improving the quality of primary healthcare will have a positive effect on the standards of care that people with chronic diseases receive. To explain this correlation, Dr. Wagner uses Sutton’s Law to point out that the emphasis on primary care is needed to access the bulk of the patients. However, primary care is becoming more complicated as the demographics, lifestyles and prevalence rates of diseases change. The fact that half of all adult outpatient visits are for chronic care emphasizes the changes that have taken place within the patient demographics.

Dr. Wagner then addresses the outcomes that patients need from the system. One of the results he notices is a lasting healing relationship. Patients also need proper self-management, preventive actions from medical professionals and monitoring. These needs help to make sure that the patients are comfortable as they continue to live with the long-term diseases. Dr. Wagner also looks at evidence showing changes to primary care systems that are leading to better results for patients. One of these changes includes the effective involvement of non-physician experts in the process of treating patients. Another change is the introduction of self-management support, where physicians work with patients in the decision-making process. The speaker also notes that the intensification of treatment and the use of electronic record keeping are changes that experts link with better outcomes. The changes form the basis of the Chronic Care Model.

Speaking on the Chronic Care Model, Dr. Wagner explains that an essential part of the program is the productive interaction between the physician team and the proactive patient. This requires both parties to be actively involved in the treatment processes and be well informed. The speaker surmises the effectiveness of the Chronic Care Model into four categories. The first category entails randomized controlled trials of interventions to improve long-term illness care. The second category is the study if the relationship between organizational characteristics and the quality of the care provided. The third category entails evaluations of the implementation of the Chronic Care Model to help improve the quality of health services. The last category involves the use of randomized controlled trials within Chronic Care Model interventions. The speaker also explains that the patient needs of the model are related to a number of roles and functions. Such as medication management, self-management support, care management, population management and care coordination.

Dr. Wagner also covers the issues of care management and care coordination. He explains that patients who are suffering from multiple complicated problems benefit from management that is more intensive in nature. This management can be handled by anyone with medical training such as a nurse, with the doctor maintaining regular contact through phone calls and other forms of communication. In care coordination, experts create links with each other so that they can effectively treat patients in a cooperative effort.

In the last part of the video, Dr. Wagner looks at the way that successful practices have helped in the implementation of CCM. The practices have seen clinics form cohesive teams that meet regularly to discuss issues. Through the practices, team members have performed at high levels of efficiency both to the benefit of the team and the patients. Effective teams have also planned and organized patient visits with great success. Planned visits, in this case, refer to encounters in which patient data, decision support and team organization ensure that there is productive dealings between the team and the patient. Successful teams also use electronic records and patient registries. These tools make it easier to plan visits and coordinate treatments. Lastly, successful teams work together with the communities of their patients to help deliver the medical services.


            This video features Dr. Ed Wagner making a presentation at the Australasian Long-term Health Conditions Conference. The focus of Dr. Wagner’s presentation was the Chronic Care Model and the different issues surrounding it such as implementation, basis and effectiveness. The presentation starts with Dr. Wagner explaining the problem facing healthcare systems in the developed world He states that part of the problem comes from aging populations. Wagner explains that the problem requires changes in the system to help improve the quality of care. Some of these changes should include more attention to the patient’s desired outcomes. Wagner emphasizes the need for productive integration between patients and their physicians. Two more issues that Dr. Wagner covers are care management and care coordination. Both involve cooperative efforts towards treating patients and improving the quality of care that they are receiving.

  1. Improving chronic illness care (


This video clips features Dr. Wagner discussing the Chronic Care Model. Dr. Wagner starts by explaining that experts can apply the model to a wide range of medical problems without any limitations to a particular field. He states that the model is applicable to deal with mental health, problems, behavioral problems as well as addictions. After this, Dr. Wagner proceeds by detailing how much the issue of chronic illnesses is affecting the United States.  The speaker states that as many as 100 million Americans are living with long-term diseases with forty percent of them having debilitations because of the illnesses. Dr. Wagner also states that the problem is costing the country up to a trillion dollars a year without guaranteeing that the care is of proper quality. Another problem that Dr. Wagner outlines is the number of conditions that some of the beneficiaries of the Medicare system have. He states that a quarter of all Medicare beneficiaries have four chronic conditions and they consume a disproportionate amount of the funding and resources in the system.

After looking at the problem, Dr. Wagner states the evidence that experts used to indicate the problems within the system. The researchers obtained some of the evidence by looking at interventions that sought to improve the primary care of people with Diabetes. The studies were looking to see whether it was possible to reduce the variation and increase the quality of the health services within the auspices of primary care. In accordance with this, Dr. Wagner explains that interventions can be classed in four categories based on the purpose.

The next part of the video sees Dr. Wagner look at the ways that experts can change the healthcare system to affect the outcomes positively. He explains that integrated changes can work when physicians direct their components at influencing the behaviour of medical experts, enhancing the use of information systems and improving self-management support. Dr. Wagner then looks at four elements that can help improve the outcomes of the health services. Firstly, there is a need for people to understand the clinical interventions that make a difference in treatment. Other things that can help improve the quality of the health services are system change strategy, system change concepts and a learning model.

Dr. Wagner then explains why the Chronic Care Model is a good option for improving care quality. Firstly, the model focuses more on improving outcomes than anything else. To achieve this, all parties (including the patient) work towards the enhancement of interaction and coordination between them. Additionally, the model also integrates the community within it to help provide support for the patients and their families. The Chronic Care Model has several key elements within it that help make it work seamlessly. One of the key elements is the coordination between the patient and the physician team. Here, the patient must be active and informed, while the physicians need to cooperate and work as a team. Another important element is self-management support. Self-management support emphasizes the need for a patient to have a central role in his or her own treatment. The remaining four elements of the Chronic Care Model are delivery system design, case management, decision support and clinical information system. Dr. Wagner also explains that another important part of the Chronic Care Model entails community resources and policies. Patients can get a lot of support from the community through a range of services and systems that they cannot within the primary care system.


This video clip features Dr. Ed Wagner giving a speech on the Chronic Care Model. Dr. Wagner starts by explaining that the nature of health problems in America is increasing. The number of people with long-term illnesses is growing and currently stands at 100 million, forty percent of the country. Researchers looked into possible solutions to the problem by studying interventions and found various ways through which experts can change the system to make it more effective. The Chronic Care Model is one way of making the American healthcare system cheaper and more effective. The Chronic Care Model features six main elements. These elements distinguish the model from primary care and help improve the quality of the health services that patients receive. The six elements are productive interactions, self-management support, delivery system design, case management, decision support and clinical information system.

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