Care Model Six


Care Model Change Package

Component #6: Organization and Health Systems

Develop leadership support for improvement of chronic illness care through visible and measurable goals in the organization’s business and strategic plans, including evidence-based provider incentives.

Change Concepts and Strategies

Evidence-Based Interventions and Testable Ideas

6.1 Define and communicate priorities and progress to relevant practice members, senior leaders, and staff on a regular basis.
  1. Recruit a project champion to take ownership of the project.
  2. Align project goals with organizational mission/goals.
  3. Design a system to provide routine project progress reports to key leaders, managers, and staff.

6.2 Integrate chronic disease management into the strategic, business, and quality improvement plans for your practice.

  1. Align project goals with organizational goals and annual plan.
  2. Create multi-disciplinary disease management team defining individual roles and responsibilities.
  3. Include all levels of staff participation in quality improvement and disease management projects.
  4. Develop a process to routinely review the QI plan with all staff and define roles and responsibilities.

6.3 Develop and promote the business case for your project as it relates to clinical, operational, and financial goals and outcomes.

  1. Integrate assessments, treatments, and services into the system of care delivery through the use of protocols that explicitly state what needs to be done for patients, by whom, and at what intervals.
  2. Regularly assess outcomes, satisfaction and cost compared to performance to remain aligned with business care plans.

6.4 Create strategies to spread successful changes to other clinical conditions, sites, providers, and teams.

  1. Document all successful interventions and strategies as initiated in preparation for spreading later; plan ahead.

6.5 Empower teams to create and sustain systems changes.

  1. Conduct regular employee staff meetings.
  2. Align quality improvement projects with organizational goals.
  3. Integrate interventions into existing established procedures.

6.6 Actively participate in the development of community health policies to improve diabetes.

  1. Develop a plan with employer groups, medical groups, health plans, Independent Practice Associations (IPAs) or other payors to ensure coverage for diabetes education and case management benefits.
  2. Coordinate services with hospital services organizations and health plans for free or low-cost diabetes education programs.
  3. Actively participate in a local or statewide diabetes collaborative.

6.6 Actively participate in the development of community health policies to improve diabetes.

  1. Develop a plan with employer groups, medical groups, health plans, Independent Practice Associations (IPAs) or other payors to ensure coverage for diabetes education and case management benefits.
  2. Coordinate services with hospital services organizations and health plans for free or low-cost diabetes education programs.
  3. Actively participate in a local or statewide diabetes collaborative.

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