Research ArticleOriginal Research
Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care
Pamela A. Ohman Strickland, Shawna V. Hudson, Alicja Piasecki, Karissa Hahn, Deborah Cohen, A. John Orzano, Michael L. Parchman and Benjamin F. Crabtree
The Journal of the American Board of Family
Medicine May 2010, 23 (3) 295-305; DOI: https://doi.org/10.3122/jabfm.2010.03.090141
Pamela A. Ohman Strickland
PhD
Shawna V. Hudson
PhD
Alicja Piasecki
MPH
Karissa Hahn
MPH
Deborah Cohen
PhD
A. John Orzano
MD, MPH
Michael L. Parchman
MD
Benjamin F. Crabtree
PhD

References
- ↵Nutting PA, Dickinson WP, Dickinson LM, et al. Use of chronic care model elements is associated with higher-quality care for diabetes. Ann Fam Med 2007; 5: 14–20.
- Glasgow RE, Hiss RG, Anderson RM, et al. Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care 2001; 24: 124–30.
- ↵Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001; 79: 579–612, iv–v.
- ↵Parchman ML, Pugh JA, Wang CP, Romero RL. Glucose control, self-care behaviors, and the presence of the chronic care model in primary care clinics. Diabetes Care 2007; 30: 2849–54.
- ↵Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health Serv Res 2002; 37: 791–820.
- ↵Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model. Part 2. JAMA 2002; 288: 1909–14.
- ↵Schmittdiel J, Mosen DM, Glasgow RE, Hibbard J, Remmers C, Bellows J. Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions. J Gen Intern Med 2008; 23: 77–80.
- ↵Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clinical Prac 1998; 1: 2–4.
- ↵Hess R, Bryce CL, Paone S, et al. Exploring challenges and potentials of personal health records in diabetes self-management: implementation and initial assessment. Telemed J E Health 2007; 13: 509–17.
- ↵Kirsh S, Watts S, Pascuzzi K, et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care 2007; 16: 349–53.
- Orzano AJ, Strickland PO, Tallia AF, et al. Improving outcomes for high-risk diabetics using information systems. J Am Board Fam Med 2007; 20: 245–51.
- Parchman ML, Zeber JE, Romero RR, Pugh JA. Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study. Med Care 2007; 45: 1129–34.
- ↵Williams GC, Lynch M, Glasgow RE. Computer-assisted intervention improves patient-centered diabetes care by increasing autonomy support. Health Psychol 2007; 26: 728–34.
- ↵Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q 2007; 85: 69–91.
- ↵Lyznicki JM, Young DC, Riggs JA, Davis RM. Obesity: assessment and management in primary care. Am Fam Physician 2001; 63: 2185–96.
- ↵Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med 2006; 4: 317–26.
- ↵Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001: CD001481.
- ↵
- ↵Caruso LB, Clough-Gorr KM, Silliman RA. Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease. J Am Geriatr Soc 2007; 55: 1656–62.
- Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O'Connor PJ. Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med 2006; 4: 310–6.
- Gilmer TP, Philis-Tsimikas A, Walker C. Outcomes of Project Dulce: a culturally specific diabetes management program. Ann Pharmacother 2005; 39: 817–22.
- ↵Pearson ML, Wu S, Schaefer J, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res 2005; 40: 978–96.
- ↵Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care 2006; 29: 811–7.
- ↵Rogers JC. The patient-centered medical home movement–promise and peril for family medicine. J Am Board Fam Med 2008; 21: 370–4.
- ↵Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med 2008; 21: 427–40.
- ↵Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42: 121–30.
- ↵Lipsitz SR, Kim K, Zhao L. Analysis of repeated categorical data using generalized estimating equations. Stat Med 1994; 13: 1149–63.
- ↵Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA 1999; 282: 1576–8.
- ↵
- ↵Overweight, obesity, and health risk. National Task Force on the Prevention and Treatment of Obesity. Arch Intern Med 2000; 160: 898–904.
- ↵U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.
- ↵Eaton CB, McBride PE, Gans KA, Underbakke GL. Teaching nutrition skills to primary care practitioners. J Nutr 2003; 133: 563S–6S.
- Rippe JM, Crossley S, Ringer R. Obesity as a chronic disease: modern medical and lifestyle management. J Am Diet Assoc 1998; 98: S9–15.
- ↵
- ↵
- ↵Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med 2007; 5: 196–201.
- ↵
- ↵Cohen D, McDaniel RR Jr, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag 2004; 49: 155–68, discussion 69–70.
- ↵
- ↵
- ↵Hudson SV, Ohman-Strickland P, Cunningham R, Ferrante JM, Hahn K, Crabtree BF. The effects of teamwork and system support on colorectal cancer screening in primary care practices. Cancer Detect Prev 2007; 31: 417–23.
- ↵
- ↵Woolf SH, Johnson RE. The break-even point: when medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med 2005; 3: 545–52.
- ↵Porter S. Focus on practice redesign, quality improvement. Ann Fam Med 2006; 4: 86–7.
- ↵
- ↵Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes Educ 2005; 31: 225–34.
- ↵Siminerio LM, Piatt GA, Emerson S, et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ 2006; 32: 253–60.
- ↵
- ↵Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009; 28: 75–85.
- ↵Coates RJ, Bowen DJ, Kristal AR, et al. The Women's Health Trial Feasibility Study in minority populations: changes in dietary intakes. Am J Epidemiol 1999; 149: 1104–12.
- Henderson MM, Kushi LH, Thompson DJ, et al. Feasibility of a randomized trial of a low-fat diet for the prevention of breast cancer: dietary compliance in the Women's Health Trial Vanguard Study. Prev Med 1990; 19: 115–33.
- Knutsen SF, Knutsen R. The Tromso Survey: the family intervention study–the effect of intervention on some coronary risk factors and dietary habits, a 6-year follow-up. Prev Med 1991; 20: 197–212.
- Mojonnier ML, Hall Y, Berkson DM, et al. Experience in changing food habits of hyperlipidemic men and women. J Am Diet Assoc 1980; 77: 140–8.
- ↵Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med 1999; 159: 725–31.
- Beresford SA, Curry SJ, Kristal AR, Lazovich D, Feng Z, Wagner EH. A dietary intervention in primary care practice: the Eating Patterns Study. Am J Public Health 1997; 87: 610–6.
- Beresford SA, Farmer EM, Feingold L, Graves KL, Sumner SK, Baker RM. Evaluation of a self-help dietary intervention in a primary care setting. Am J Public Health 1992; 82: 79–84.
- Scott JG, Cohen D, DiCicco-Bloom B, et al. Speaking of weight: how patients and primary care clinicians initiate weight loss counseling. Prev Med 2004; 38: 819–27.
In this issue
Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care
Pamela A. Ohman Strickland, Shawna V. Hudson, Alicja Piasecki, Karissa Hahn, Deborah Cohen, A. John Orzano, Michael L. Parchman, Benjamin F. Crabtree
The Journal of the American Board of Family
Medicine May 2010, 23 (3) 295-305; DOI: 10.3122/jabfm.2010.03.090141
Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care
Pamela A. Ohman Strickland, Shawna V. Hudson, Alicja Piasecki, Karissa Hahn, Deborah Cohen, A. John Orzano, Michael L. Parchman, Benjamin F. Crabtree
The Journal of the American Board of Family
Medicine May 2010, 23 (3) 295-305; DOI: 10.3122/jabfm.2010.03.090141
Jump to section
Related Articles
- No related articles found.
Cited By...
- Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews
- Low-Intensity Intervention Supports Diabetes Registry Implementation: A Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN)
- Conformity of Diabetes Mobile apps with the Chronic Care Model
- Patients living with disabilities: The need for high-quality primary care
- Physician Recommendation and Patient Adherence for Colorectal Cancer Screening
- The Chronic Care Model and Exercise Discussions during Primary Care Diabetes Encounters
- Policy and Financing in Family Medicine and the Medical Home