Table 1.

Chronic Care Model Operational Definitions and Items Used to Describe Them*

TermDefinitionAverage Practice Score (SD)Descriptive Items
Practice organizationAn organization that provides safe, high-quality care with leadership that encourages efforts to improve care0.04 (1.00)
  • 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.

Behavioral change supportEffective behavior change support is used to help patients and families improve their health behavior0.00 (0.43)
  • 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.§

Delivery system designOrganizational features of the practice assure well-planned visits and impact the provision of care0.00 (0.46)
  • 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)**

Decision supportClinicians have convenient access to the latest evidence-based guidelines and specialist expertise is integrated into the practice0.04 (0.57)
  • 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

Clinical information systemsData about patients is organized to facilitate efficient and effective care0.01 (0.77)
  • 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

  • * Average component scores were created as an average of z-scores from items used to assess each component.

  • Practice Staff Questionnaire (PSQ), each item scored on a 1 to 5 scale, “strongly disagree” to “strongly agree.”

  • PSQ, each item scored on a 1 to 5 scale, “never used” to “always used.”

  • § Clinical Management Survey (CMS), scored on a 1 to 5 scale, “never used” to “always used.”

  • CMS, scored on a 1 to 5 scale, “weekly,” “monthly,” “quarterly,” “annually,” “never.”

  • CMS, a count of the types of staff in attendance: physicians, other clinicians, nursing staff, office staff.

  • ** Patient survey, scored 1 to 5, “never” to “always.”

  • †† PSQ, 0 or 1 for “not used” or “used.”

  • PDA, personal digital assistant.