Implementing the Chronic Care Model: Fostering Partnerships in Rural Primary Care

Objective:  The Chronic Care Model (CCM) is an effective framework for enhancing the quality of diabetes care and provides structure for care using the following elements: community, health system, self-management support, delivery system design, decision support, and clinical information systems.  Little is known about priorities for implementing activities that address these elements in primary care.  Our objective was to implement the CCM in primary care practices in rural southwestern Pennsylvania by establishing priorities for implementation.

Methods:  Partnerships were established with diabetes centers in the rural areas.  Diabetes educators from these centers identified primary care practices and asked them to participate in a focus group regarding diabetes care.  Focus groups were conducted in thirteen primary care practices.  Participants included physicians, nurse practitioners or physician assistants, and other office staff.  The practice received a brief overview of the CCM followed by a discussion of immediate (1-3 months), intermediate (3-6 month), and long-term priorities (6-12 months). 

Results:  Practices most often identified self-management support (diabetes education in their practices) and delivery system design (diabetes days) as immediate priority areas.  Intermediate goals were related to the community (health related events and awareness) and health system (reimbursement).    Practices were interested in either implementing or enhancing clinical information systems (electronic health records) as a longer term goal. 

Conclusion:  Primary care providers in this rural area are most concerned about access to diabetes education and community awareness.  These results will be used to facilitate interventions to improve diabetes outcomes by meeting practices’ identified needs as prioritized by them.