CCM-Diabetes

Ns. Heri Kristianto, MKep.,Sp.Kep.MB (CTN)

MK: Keperawatan Kronis/ IK/ FKUB-2017

Introduction

major chronic disease

Diabetes mellitus is currently a economic and
social development
The chronic care model (CCM) was developed to provide chronic disease patients, including

those with type 2 diabetes mellitus (T2DM)

The model represents a method for restructuring health care through interactions between

health systems and communities

In addition, the model collects basic data that can be used for improving care in health systems

community, clinical practice, and patient

at the

levels
Purposes of CCM

The CCM aims to improve and optimize six key, interrelated elements of the health system
1. Organization of health care (Organisasi Sistem Pelayanan Kesehatan)
2. Self management support (Dukungan manajemen diri)
3. Decision support (Dukungan Pengambilan Keputusan)
4. Delivery system design (Desain system layanan)
5. Clinical information systems (system Informasi Klinik)
6. Community resources and policies (Kebijakan dan Pemberdayaan Masyarakat)

improve the use of existing resources,

The essential focus of the model is to

create new resources, and promote a new policy of intera

ction between more enlightened and empowered patients and better prepared and proactive
health teams
Organization of health care
 The organization of health care services should focus
on creating a culture and mechanisms that promote
safe, high quality care.
To enhance health care, improvements to service or
ganization, introduction of strategies to facilitate
changes, and management of errors and quality
control problems are also necessary.
Problems of miscommunication and coordination
of health care must be prevented through agreeme
nts that facilitate communication and the flow of info
rmation between managers and service providers.
Information system
Wagner EH, Grothaus LC, Sandhu N, Galvin MS, McGregor M, Artz K,
Coleman EA. Chronic care clinics for diabetes in primary care: a syste
m-wide randomized trial. Diabetes Care. 2001;24:695700.

Wagner et al. compared a usual care program wit

h standardized assessments, visits with the
primary care physician, nurse, and clinical
pharmacist, and a group education/peer
support meeting. After 24 months of intervention
, there was no significant difference in HbA1c an
d total cholesterol between the two groups.
Self management support

Interventions targeted user empowerment by emphasizing the role of users in

1. managing their own health
2. the use of support strategies for self-care (including assessment of health status)
3. goal setting
4. plan of care preparation and monitoring

Both the patient and provider should be included in

1. defining problems
2. setting priorities
3. proposing goals
4. developing care plans
5. monitoring results for self-care

Health professionals should prioritize collaborative care management so that prescri

bers become partners with health care system users
self-responsibility related to health including regular use of evidence-
based support programs

1. provided information
2. emotional support
3. strategies for living with chronic conditions
Glasgow RE, Nutting PA, King DK, Nelson CC, Cutter G, Gaglio B, Rah
m AK, Whitesides H. Randomized effectiveness trial of a computer-as
sisted intervention to improve diabetes care. Diabetes Care. 2005;28:
339.
Glasgow et al., compared standard care with an interactive computer-ba
sed program. The first part of the program focused on the medical care
participants were receiving for diabetes while the second part focused on
development of a self-management action plan. Intervention patients ans
wered questions regarding their dietary habits, physical activity, and smok
ing behaviors and then received feedback in each of these areas. Next, pa
rticipants selected a behavior change goal in the area of smoking, diet, or
exercise. After 6 months, both the control and intervention participant
s showed improved lipid and HbA1c levels, but there was no significa
nt difference between the two groups.
Decision support

To increase user understanding, clinical decisions should be discussed

and made together with the users.
To change practices, clinical guidelines should include system alerts, r
eminders, and feedback
Delivery system design

These changes aimed to organize user data to facilitate the efficiency

and effectiveness of the health care system
Alerts, reminders, and timely feedback for health professionals as well
as service users should be used when organizing user data.
Organization of user data should also summarize clinical information
to help identify risk groups that require different health care approach
es and to allow for the monitoring of system performance and efforts
made in order to provide better service quality
Clinical information systems

Alerts, reminders, and timely feedback for health professionals as well

as service users should be used when organizing user data.
Organization of user data should also summarize clinical information
to help identify risk groups that require different health care approach
es and to allow for the monitoring of system performance and efforts
made in order to provide better service quality
Information system more efficient and effective
Smith SA, Shah ND, Bryant SC, Christianson TJH, Bjornsen SS, Giesler
PD, Krause K, Erwin PJ, Montori VM. Chronic care model and shared
care in diabetes: randomized trial of an electronic decision support s
ystem. Mayo Clin Proc. 2008;83:74757.

In the 2008 study conducted by Smith et al. [19], those receiving a telem
edicine intervention, which provided specialized advice and evidence-ba
sed messages regarding medication management for cardiovascular risk,
were compared with those not receiving an intervention. After an average
of 21 months (range 336 months), blood pressure (BP), HbA1c, low-dens
ity lipoprotein cholesterol, creatinine, and microalbumin levels were comp
ared between the groups; however, the authors found that the interventi
on did not significantly enhance metabolic outcomes when compared
with control
Design of the service delivery system

Improving the health of people with chronic conditions requires trans

forming a health care system that is essentially reactive, episodic, ev
ents focused, and responds to demands and acute conditions into
a system that is proactive, integrative, continuous, and focuses on
the person and family and is devoted to promoting and maintaini
ng health.
This requires that health care needs as well as roles and tasks be def
ined to ensure that users receive structured attention that is planned
and provided by a multidisciplinary team.
It means introducing new forms of care that go beyond face-to-face
consultation (as a means of shared attention away from groups) to s
ustained attention, peer attention, and attention from a distance.
The objective is to increase the amount of calls scheduled in advan
ce to ensure that these calls are not made through spontaneous
demand
Goderis G, Borgermans L, Grol R, Van Den Broeke C, Boland B, Verbe
ke G, Carbonez A, Mathieu C, Heyrman J. Start improving the quality
of care for people with type 2 diabetes through a general practice s
upport program: a cluster randomized trial. Diabetes Res Clin Pract.
2010;88:5664.

Goderis et al., assessed improvements in high-density lipoprotein choleste

rol (HDL-C), total cholesterol, diastolic blood pressure (DBP), weight, and
smoking status, as well as statin and antiplatelet therapy efficacy between
a usual care and an intervention group. The 18-month intervention focus
ed on an intensified follow-up, shared care, and patient behavioral chang
es. No significant additional improvements were found for the outcomes i
n the intervention group when compared with control group.
Schillinger D, Handley M, Wang F, Hammer H. Effects of self-manage
ment support on structure, process, and outcomes among vulnerabl
e patients with diabetes: a three-arm practical clinical trial. Diabetes
Care. 2009;32:55966.
In the Schillinger et al. study in 2009, patients were assigned to one of th
ree groups: (1) standard care, (2) an interactive weekly automated telepho
ne self-management support with nurse follow-up intervention, or (3) mo
nthly group medical visits from a physician with health educator facilitatio
n. Clinical outcomes, such as glycemic control, HbA1c, systolic blood pres
sure (SBP), DBP, and body mass index (BMI), were assessed after 9 month
s. Glycemic control improved across all three arms, but there were no stat
istically significant differences in HbA1c, SBP, DBP or BMI change across t
he three groups.
Community resources and
policies

Mobilize resources to meet the needs of users

through community programs and partnerships
between health organizations and community
organizations
The goal of this element is to develop progra
ms that benefit users and improve health care
policies
Glasgow RE, Kurz D, King D, Dickman JM, Faber AJ, Halterman E, Wo
oley T, Toobert DJ, Strycker LA, Estabrooks PA, Osuna D, Ritzwoller D.
Outcomes of minimal and moderate support versions of an internet-
based diabetes self-management support program. J Gen Intern Me
d. 2010;25:131522.

In the Glasgow et al. , one group received a self-administered, computer-

assisted, self-management (CASM) program with personalized goals and
action plans for medication taking, healthy eating, and BP while the other
received the CASM program with social support (i.e., follow-up calls from
intervention personnel) and was invited to attend a group session. Both g
roups were compared against the usual care group. No significant differe
nces were found for the HbA1c, BMI, lipids, and BP outcomes between th
e groups at the 4-month follow-up.
Conclusions

Prevention and early intervention associated with integrated mana

gement can be a multidimensional and systemic solution to the di
fficult and complex problem of how to provide care for chronic co
nditions, such as diabetes. Our review shows that the use of isolat
ed components of CCM does not seem to be enough to improve
clinical outcomes; however, it is possible that greater benefits coul
d be obtained through interventions combining CCMs six element
s.
Referensi

1. Stellefson M, Dipnarine K, Stopka C. The chronic care model and

diabetes management in US primary care settings: a systematic review.
Prev Chronic Dis. 2013;10:E26.
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for
patients with chronic illness: the chronic care model, Part 2. JAMA.
2002;288:190914.
3. Wagner EH, Grothaus LC, Sandhu N, Galvin MS, McGregor M, Artz K,
Coleman EA. Chronic care clinics for diabetes in primary care: a system-
wide randomized trial. Diabetes Care. 2001;24:695700.
4. Strickland PAO, Hudson SV, Piasecki A, Hahn K, Cohen D, Orzano AJ,
Parchman ML, Crabtree BF. Features of the chronic care model (CCM)