Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care

People in our practice actively seek new ways to improve how we do things.^†

The practice leadership makes sure that we have the time and space necessary to discuss changes to improve care.^†

Most people in this practice are willing to change how they do things in response to feedback from others.^†

Use of patient questionnaire at either the first visit or routine visits to identify patients who may benefit from counseling for eating habits, physical activity, smoking, alcohol use and cancer screening (maximum across first and routine-use responses and then averaged across behavior categories).^‡

Refer out for counseling or screening (averaged across behavior categories).^‡

Use nurses or health educators within the practice for individual counseling or use group counseling activities (averaged across behavior categories).^‡

Frequency with which practices use a process or system for reminding patients about visits.^§

Frequency of clinical meetings.^‖

Inclusion of staff members with different roles in the clinical meetings.^¶

Continuity of care: When patient gets sick, they contact the practice first (before going to specialist or emergency room)^**

Computers are used for retrieving information, either through PDAs, online literature searching, a CD-based medical knowledge base or the Internet^††

Use of chart audit for chronic diseases or cancer screening^‡

Use of nurses and health educators^‡

A registry for chronic diseases.^‡

A process for identifying patients due for screening or tests.^‡

A process to prompt clinicians at the time of visits about needed tests or additional visits.^‡

Risk factor chart stickers or electronic flags^‡

Checklists or flowcharts^‡