Chronic Care Model (CCM) is a framework to provide the best care possible to

chronic patients through evidence based treatments, empowering the patient

through information and assist in decision making. The model makes use of the
practice organization, community services, support organization and the patient
himself to improve his health. Following are the components of the CCM model:
1. Organizational support includes system leadership, culture of the
organisation etc.
2. Clinical Information Systems For example, data on trends of various
parameters of patient population can help in arriving the appropriate
treatment
3. Delivery System Design Frequency of visits by practitioner/ clinician, group
visits, regular health checks, case management etc.
4. Decision Support Involves referring the patient to another expert, consulting
with other practitioners before altering the treatment etc.
5. Self-Management Support Empowering the patient with information,
involving the patient in decision making process by providing the trend data
on body parameters, assisting the patient to choose an exercise regime, diet
plan etc.
6. Community Services Involving communities, peers who can assist/ guide
the patient, interacting with different set of people etc.
These six unique concepts are identified as modifiable components to improve the
health of the patient population.
Based on the above description, a role can fall under a single component or can be
under multiple components.
Administration, Billing and Finance, Coding Analysts, Credentialing
Coordinator, Facilities Management, Housekeeping, Human Resources,
Information Management, Security, Quality Improvement Specialist,
Marketing and Pharmacy:
These roles fall under organizational support. Making a hassle free billing process
for the patients, maintaining the official records of patients with utmost quality
indirectly help in improving the healthcare given to the patient population
(Administration, Billing and Finance). Identification of billable services, sequencing
the diagnostic procedures as per requirements are all part of organizational support
(Coding Analyst).
Credentialing Coordinator & Quality Improvement Specialist: Carrying out
credentialing processes of physicians, medical assistants and other facilities. Making
sure the processes are followed in compliance with government laws, company
policies etc. ensure quality healthcare delivery for the patient.
Facilities Management & Housekeeping: Similarly, properly managing the facilities,
regular maintenance of the medical devices enable the organization to provide
critical support for the patient at the right time.

On the same lines having a functional pharmacy, reliable security, an effective

human resources team that recruits the best practitioners and assistants provide
the required organizational support to treat the patient.
Dietician Based on patient current status, dietician can assist the patient in
choosing the right diet, by providing the required information. Dietician hence is
part of self-management support.
Health Economics By studying the pattern among various patients, various
situations, this field assists the patient with information to avoid/choose things.
Hence this falls under Self-management support.
Laboratory, Radiology and Medical Records help to measure the patient
critical parameters and to maintain the trend data along with confidentiality. These
help the practitioners to make decisions about patients health/ improvement plan.
Hence they are under Clinical Information System.
Similarly, Nursing & Medicine fall under Delivery system design. Social Work falls
under Community services. Risk Management under organizational support.