Community Resources and Policies


  • Encourage patients to participate in effective community programs;
  • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services;
  • Advocate for policies to improve patient care and community care facilities;
  • Provide a lay care coordinator;
  • Self-management and social support.


  • Home care by outreach nurses programs (Wong)
  • Volunteer care coordinator (IOM)
  • Patient navigator for colorectal cancer screening (Jandorf) 
  • Patient navigator for breast cancer (Robinson-White)
  • Peer education for prostate cancer (Weinrich)
  • Lay health worker educational program for increasing breast cancer screening (Lewin)

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•Health Care Organization


  • Visible support improvement at all levels of the organization, beginning with senior leadership;
  • Promote effective quality improvement strategies aimed at comprehensive system change;
  • Encourage open and systematic handling of errors and quality problems to improve care;
  • Provide incentives (financial or otherwise) based on quality of care;
  • Develop agreements that facilitate coordination within and across different treatment settings and levels of care.


  • Structuring monitoring of risk factors and prescribing (Buckley)
  • Ambulatory comprehensive care programs (De Bruin)
  • Use of the Chronic Care Model as a framework for interventions aiming to improve asthma therapy adherence (Moullec)
  • Interventions focused on specific risk factor or functional difficulties for people with multiple chronic conditions (Smith)
  • Financial incentives in particular the modality of group level financial incentives (Petersen, Scott)
  • Multifaceted professional interventions (Renders)
  • Enhancing performance of health professionals (Renders)
  • Hypertension care quality improvement strategy involving physicians and other team members (Walsh)

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Clinical Information System


  • Monitor response to treatment;
  • Supervise individual and group of patients;
  • Provide timely reminders for providers and patients;
  • Identify relevant subpopulations for proactive care;
  • Facilitate individual patient care planning;
  • Share information with patients and providers to coordinate care; 
  • Monitor performance of practice team and care system;
  • Use care plan reminders.


  • Introducing health information technology, in particular electronic medical records (Shekelle)
  • Conducting periodic audit of medical records and (Ivers)
  • Giving feedback to providers about the quality of care (Ivers)
  • Point of care computer reminders (Shojania 2006, Shojania 2009)
  • Case management in conjunction with disease management for diabetes (Norris)
  • Education, reminders and patient support interventions for diabetes (Norris)
  • Central computerized patient tracking system  (Renders)
  • Nurses who regularly contact patients (Renders)
  • Reviewing patients in a central computerized system  (Renders)

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Decision Support


  • Disseminate CNCDs evidence-based guidelines;
  • Use technically-sound methodology to develop or adapt new guidelines;
  • Evaluate existing guidelines;
  • Ensure evidence-based guidelines are updated periodically;
  • Embed evidence-based guidelines into daily clinical practice;
  • Integrate specialist expertise and primary care;
  • Use the shared care modality;
  • Use proven health worker education methods;
  • Share guidelines and information with patients.


  • Clinical decision-support systems (Bright) 
  • Guideline-driven care (Thomas)
  • Mailing printed bulletin with a single clear message containing systematic review of evidence (Murthy)
  •  Shared care to improve prescribing (Smith)
  • Educational meetings, giving healthcare professionals feedback, learning materials, and using patient decision aids (Légaré)
  • Use of computerized clinical decision support systems in primary care (Souza) 
  • Aids and support for clinical decisions (Stacey)
  • Assigning a role in decision support to a clinical provider (Watts)

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Delivery System Design


  • Organize PHC based care;
  • Define roles and distribute tasks among team members;
  • Ensure proactive care and regular follow-up;
  • Use risk stratification;
  • Provide case management or  a care coordinator for patient with complex diseases;
  • Give care that patients understand and that conforms to their cultural background;
  • Develop integrated health service delivery networks.


  • Clinical record audit and feedback (Jamtvedt 2006)
  • Assigning a role in self-management, decision support and delivery system design to a designated clinical provider (Watts)
  • Implementing a personalized structured discharge plan (Shepperd)
  • Referral guidelines and forms (Akbari) 
  • Using regular planned recall of patients for appointments (Buckley)
  • Chronic care management programs for diabetes (Elissen)
  • Program of nurses contacting frequently with patient (Renders)

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Self-Management Support


  • Ensure patient participation in the process of care;
  • Promote the use of lay or peer educators;
  • Use group visits;
  • Develop patient self-regulatory skills (i.e., managing health, role and emotions related to chronic conditions);
  • Promote patient communication skills (especially with regard to interactions with health professionals and the broader health system);
  • Negotiate with patient goals for specific and moderately challenging health behavior change;
  • Stimulate patient self-monitoring (keeping track of behaviors);
  • Promote environmental modification (creating a context to maximize success);
  • Ensure self-reward (reinforcing one's behavior with immediate, personal, and desirable rewards);
  • Arrange social support (gaining the support of others); 
  • Use the 5As approach during routine clinical encounters.


  • Group based self-management support for people with type 2 diabetes (Deakin)
  • Self-monitoring of blood pressure specially adjunct to care (Glynn)
  • Patient educational intervention for the management of cancer pain alongside traditional analgesic approaches (Bennett)
  • Patient educational intervention using the 5 As for reducing smoking, harmful use of alcohol and weight management (Goldstein)
  • Training for better control blood glucose and dietary habits for people with type 2 diabetes (Norris)
  • Lay educator led self-management program for people with chronic conditions, including arthritis, diabetes, asthma and COPD, heart disease and stroke (ASMP, National Primary Care Research, Kennedy)
  • Self-management support that involves a written action plan, self-monitoring and regular medical review for adults with asthma (Gibson)
  • Self-management support for people with heart failure to reduce hospital readmission (Jovicic 2006)
  • Patient oriented interventions such as those focused on education or adherence to treatment (Renders)

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The Chronic Care Model

Several organizational models for CNCD management have been proposed and implemented internationally. Perhaps the best known and most influential is the Chronic Care Model (CCM; see Figure 1), which focuses on linking informed, activated patients with proactive and prepared health care teams. According to the CCM, this requires an appropriately organized health system linked with necessary resources in the broader community. A number of countries have implemented (adopted or adapted) the CCM. In 2002, WHO produced an expanded version of the model—the Innovative Care for Chronic Conditions (ICCC) Framework, which gives greater emphasis to community and policy aspects of improving health care for chronic disease. Other related models are being used to guide the provision of CNCD care within certain countries.

The Chronic Care Model

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Executive Summary

Care for chronic noncommunicable diseases (CNCDs) such as cardiovascular disease (CVD), diabetes, cancer, and chronic obstructive pulmonary disease (COPD) is a global problem. Research demonstrates that the vast majority of people with CNCDs do not receive appropriate care.

Full Document:

Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care for Chronic Noncommunicable Diseases in the Americas
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the document

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This report describes a model of health care that could deliver integrated management of NCDs within the context of primary health care (PHC), and provides practical guidance for health care program managers, policy-makers, and stakeholders on how to plan and deliver high-quality services for people with CNCDs or CNCD risk factors. Key implications of integrated management at the policy level are also discussed, including the financial and legislative aspects of care and human resource development. The report includes a list of examples of effective intervention for each component of the Chronic Care Model. Furthermore, unpublished country based examples of the implementation of good practices in chronic care are showcased throughout the document.

The document concludes that the Chronic Care Model should be implemented in its entirety since its components have synergistic effects, where the whole is greater than the sum of the parts. Policy reforms and universal access to care are critical elements leading to better outcomes and reducing disparities in chronic disease care. It is critical to integrate PHC-based chronic care into existing services and programs. Chronic diseases should not be considered in isolation but rather as one part of the health status of the individual, who may be susceptible to many other health risks. A patient-centered care system benefits all patients, regardless of their health conditions or whether his/her condition is communicable or noncommunicable.

A care system based on the Chronic Care Model is better care for all, not only for those with chronic conditions. Primary care has a central role to play as a coordination hub, but must be complemented by more specialized and intensive care settings, such as diagnostic labs, specialty care clinics, hospitals, and rehabilitation centers. Finally the ten recommendations for the improvement of quality of care for chronic conditions are:

  1. Implement the Chronic Care Model in its entirety.
  2. Ensure a patient centered approach. 
  3. Create (or review existing) multisectoral policies for CNCD management including universal access to care, aligning payment systems to support best practice.  
  4. Create (or improve existing) clinical information system including monitoring, evaluation and quality improvement strategies as integral parts of the health system. 
  5. Introduce systematic patient self-management support. 
  6. Orient care toward preventive and population care, reinforced by health promotion strategies and community participation.
  7. Change (or maintain) health system structures to better support CNCD management and control.
  8. Create PHC-led networks of care supporting continuity of care.
  9. Reorient health services creating a chronic care culture including evidence-based proactive care and quality improvement strategies.
  10. Reconfigure health workers into multidisciplinary teams, ensuring continuous training in CNCD management.

Click on the title to learn more:

altComprehensive integrated care, self-care, patient support and education, training for healthcare workers to improve the quality of care: This team works to facilitate and support the strengthening of the capacity and competencies of the health system for the integrated management of chronic noncommunicable diseases (CNCDs) and their risk factors. These functions are among the core elements of the CARMEN Network and the pdf Regional Strategy  for Chronic Disease Prevention and Control. The team follows the Chronic Care Model, as described below. Also click below for a list of relevant documentation and resolutions.


Passport to healthy lifestyle 2014

Chronic Care Passport

Chronic Care Passport 2012

Chronic care passport for professionals

Chronic care passport for professionals

Healthy Living for Patients

Healthy Living for Patients

Innovative Care for Chronic Conditions

Innovative Care for Chronic Conditions

The Chronic Care Passport is a patient-held card used by patients with CNCDs such as diabetes, hypertension and chronic obstructive pulmonary disease.

CAMDI multinational surveyThe Central American Diabetes Initiative (CAMDI) conducted a series of surveys in Central America, with the following objectives:

  • Determine the prevalence of diabetes mellitus and hypertension in people 20 years of age and older in a sample taken from six Central American populations (urban areas of San José, Costa Rica; Santa Tecla, San Salvador, El Salvador; Villanueva, Guatemala City, Guatemala; Tegucigalpa, Honduras; and Managua, Nicaragua; and the national population of Belize).
  • Determine the prevalence of major risk factors diabetes and hypertension in six Central American populations.