Chronic Care Model: Meet the Needs of Specific Populations

Teams working with unique groups may need to emphasize some model elements more than others. For example, Self-Management and Adherence is very important migrant populations who may seek health care in several geographic areas, while Community linkages are crucial when working with homeless populations. In some cases, adaptation of key changes will be necessary such as using pictorial educational information for populations with low literacy.
 
Consider the following changes from the Chronic Care Model to improve the care of people living with HIV/AIDS disease in special organizational settings or patient populations.
 
 

Rural/Small Setting

Self-Management and Adherence:
  • Be creative in planning self-management programs that overcome distance barriers (e.g., suggest electronic chat rooms instead of face-to-face support groups).
  • Overcome long travel distances for traditional visits by monitoring progress by phone or email.

 

Decision Support:
  • Use distance communications, such as telemedicine or phone consultation with a specialist, whenever possible.
  • Bring specialists in periodically. Be creative in recruiting methods (e.g., fly the specialist to the clinic once a quarter).
 
Clinical Information System:
  • Combine resources with other rural/small health centers or clinics within the region.
  • Use off-the-shelf software to develop a registry or scheduling system.
 
Delivery System Design:
  • Ensure cross-training of staff.
  • Use planned visits to accomplish as much as possible during a single visit.
 
Community:
  • Make coalitions with other local groups to get needed funding and services.
  • Recognize the greater need to protect confidentiality (e.g., avoid the use of labels on patient records and integrate HIV/AIDS care into existing clinics so that patients are not identified as having HIV/AIDS disease by when or where they come for care).

 

 

Urban/Large/Academic Setting

Self-Management and Adherence:
  • Overcome the barrier of staff turnover (i.e., rotating residents and fellows) to provide stable relationships with providers using stable staff (e.g., nurses, medical assistants, etc.) as the basis for the self-management intervention.
  • Ensure continuity and accountability by having outgoing residents sign off to incoming residents on his or her panel of patients.
  • Use medical students and residents to coach and mentor. Use pharmacy students to support medication adherence.
 
Decision Support:
  • Formalize the link to faculty and researchers to give providers updated training on management of HIV/AIDS disease.
 
Clinical Information System:
  • Take advantage of networks in order to share information between sites and providers (e.g., link a satellite clinic with infectious disease expertise at an academic setting).
  • Make use of existing information systems and existing technical expertise (e.g., ask information technology staff for help in importing data from the billing system into the registry).
 
Delivery System Design:
  • Overcome the barrier of staff turnover (i.e., rotating residents and fellows) by cross-training and by using stable staff (i.e., nurses, medical assistants, etc.) as the basis of the system design.
  • Capitalize on the close proximity of a variety of care providers in order to coordinate a host of services within one comprehensive visit.
 
Organization of Health Care:
  • Recognize the greater hierarchical distance to senior leaders. Make a special effort to involve them in planning and feedback.
 
Community:
  • Recognize that greater abundance of community resources makes it more important to coordinate and screen for quality programs.

 

 

Homeless

 

Self-Management and Adherence:
  • Tailor self-management tools to increase the relevance for this population (e.g., don't assume the patient has a bedside table on which to place pills).
  • Recognize that HIV infection may not be the patient's most pressing concern. Therefore, offer broad self-management support such as how to access the needed resources and how to stay connected with care providers.
 
Clinical Information System:
  • Be sure to include information on the best way to contact the patient in the registry (e.g., via relative, friend, or message left at a frequented locale).
  • Provide the patient with a card with the clinic fax number to facilitate communication from the ER to the health center or clinic.
 
Delivery System Design:
  • Embed increased outreach and flexibility into the system design for this population (e.g., provide a meal at a store-front location to induce patients to come for care and testing).
  • Make use of community outreach workers and case managers to locate patients for follow-up.
 
Organization of Health Care:
  • Enlist senior leader support for increased tolerance with policies, procedures, and financing.
 
Community:
  • Invest in outreach efforts to locate and guide patients to community resources (e.g., have outreach volunteers walk with patients to a community event).
  • Address mental health and substance abuse resource needs.

 

 

Women and Children

Self-Management and Adherence:

  • Tailor self-management planning to adapt to the nuances of the patient-child relationship and different levels of control for pediatric patients.
  • Provide tools for parenting, including counseling.
  • Recognize that women may put their children's needs before their own; investigate resources for the children.

 

Decision Support:

  • Embed the use of different guidelines (e.g., pediatric/prenatal) as needed.
  • Make use of the opportunity to focus care. Recognize the need for relationships with different specialties (e.g., obstetrician/gynecologists, certified nurse-midwives).

 

Clinical Information System:

  • Provide the patient with a card with the clinic fax number to facilitate communication from obstetrician/gynecologists and certified nurse-midwives to the health center or clinic.

 

Delivery System Design:

  • Coordinate care for these populations to reduce barriers to care (e.g., hold mother-baby clinics, provide babysitting at the health center or clinic, provide transportation, recognize the difficulties of navigating public transportation with children in tow).
  • Recognize the need for relationships with different specialties (e.g., obstetrics/gynecology).

 

Community:

  • Use community resources to provide babysitting and transportation.

 

 

Incarcerated/Institutionalized Patients

Self-Management and Adherence:

  • Be sensitive to barriers created by the institution (e.g., few opportunities for exercise, good nutritional choices, or emotional support). Actively engage the patient and the institution in planning around these barriers.

 

Delivery System Design:

  • Use directly observed therapy (ODT).
  • Forge relationships with the institution to ensure the exchange of information regarding patient status and care.

 

Organization of Health Care:

  • Use community political resources to ensure that standards of care are met.
  • Address post-discharge planning with AIDS service organizations.

 

Community:

  • Identify resources (e.g., Alcoholics Anonymous meetings) that could be brought into the institution and facilitate their entry into the system.

 

 

Patients Dually Diagnosed (Substance Abuse/Mental Health Disorder)

Self-Management and Adherence:

  • Consider medical clinic appointments to strictly monitor medication adherence.
  • Recognize that HIV infection may not be the patient's most pressing concern. Therefore, offer broad self-management support such as assessment of readiness to begin treatment and suggestions on how to stay connected with care providers.
  • Use community case managers for frequent follow-up on self-management goals.

 

Decision Support:

  • Prioritize and balance the patient's problem list; HIV infection may not be the most pressing problem.
  • Educate providers on depression and substance abuse principles and treatment.

 

Clinical Information System:

  • Track the number of patients referred to mental health or drug treatment programs and the number currently in the programs to monitor loss to follow-up.

 

Delivery System Design:

  • Use the acuity system for determining the intensity of case management and length of visit.
  • Build and document a referral system for mental health care that ensures two-way communication.
  • Consider directly observed therapy (DOT).

 

Organization of Health Care:

  • Enlist senior leaders to ensure that your organization is fully committed to caring for and removing barriers for this population.

 

Community:

  • Ensure the representation of dually diagnosed patients on the consumer advisory board.
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