In the CCM, improved functional and clinical outcomes for disease management are the result of productive interactions between informed, activated patients and the prepared, proactive practice team of clinicians and healthcare professionals. Figure 1 illustrates these two spheres of the model that interact and influence systemic change for chronic disease management. The components of this integrated effort are illustrated in the top half of the model. Quality improvement teams working with this model focus their efforts and interventions on the four areas contained in the health system oval: self-management support, delivery system design, decision support and clinical information systems. Table 1 provides an overview of and examples of interventions for the key model components of the CCM.
Evidence indicates that this organized and multifaceted support for primary care teams positively affects the care of diabetic patients (McCulloch et al. 1998). Examples of functional and clinical outcomes that resulted from applying the CCM to the care of people with diabetes included decreased levels of HbA1c and a decrease in smoking rates among patients