CCM and Organization Of Care Flashcards
What are the 2 main pieces of the CCM?
Organizational Approach
Quality Improvement Strategy.
**must be evidence based
Chronic care model being incorporated into professional practice is an important predictor of what?
10 year risk of CHD
Diabetes care must: 3
Be proactive
Be organized around the patient. Ie: patient supported in self management by inter professional team
Incorporate CCM
What are the six elements of the CCM that improve care?
DDSCCH
Delivery system design
Decision support ie clinical decision support system
Self management support
Clinical info system. Eg. EMR, patient registries
Community eg. Food. Housing security. Ability to lead active lifestyle, access to care, social supports
Health systems Eg. Incentive billing codes. Pay for performance Health promotion.
What are the 5 Rs of the organization of care?
Recognize Register Resource inter professional and self management Relay-info sharing Recall.
Using the CCM for diabetes improves what parameters? Five
The CCM improves:
- A1C
- LDL-C
- Use of statins
- Drug and hospital expenditures
- Overall mortality
Would a patient care flow sheet be an example of: Delivery system design Decision support Self management support Clinical info Community Health systems
Decision support
Would a Disease management model that uses patient education, coaching, treatment adjustment, monitoring, care co-ordination be an example of: Delivery system design Decision support Self management support Clinical info Community Health systems
Delivery system design
Would a peer-led self-management support groups be an example of: Delivery system design Decision support Self management support Clinical info Community Health systems
Community
•Promoting preventative care and appropriately planning resource allocation
An example of: Delivery system design Decision support Self management support Clinical info Community Health systems
Health systems
provider incentives for achieving milestones Is an example of: Delivery system design Decision support Self management support Clinical info Community Health systems
Health systems
Measuring units of insulin Cognitive
Psychomotor
Affective
Psychomotor
State willingness to take insulin.
Cognitive
Psychomotor
Affective
Affective
Describe action of insulin
Cognitive
Psychomotor
Affective
Cognitive
Being in the preparation stage means a person is ready to act in the next _____ days
30
Being in the contemplation stage means the person is ready to act in how long?
Within 6 months as the pros outweigh the cons for change
Motivational interviewing includes what four general principles?
Hint: EE. DD. RR. SD
Expressing Empathy
Developing Discrepancy
Rolling with Resistance
Supporting Self efficacy
If a patient says “ Diabetes is not so bad..” What stage of change are they in?
Pre-Contemplation.
If a patient says “ So I’m
Overweight. If I dieted I’d probably die of a heart attack…” What stage of change are they in?
Pre-contemplation
If a patient says “ if you just leave me alone maybe I would change!” What stage of change are they in?
Pre contemplative
What stages of the transtheoretical model of change is motivational interviewing MOST helpful?
In pre contemplation and contemplation.
Pts need to process the pros and cons of change many times before moving from pre to contemplation. They must resolve ambivalence associated with not being ready to change!
Telehealth is most successful
In resucing A1C when what
It allows for adjustment of medications.
Which individuals with diabetes should work with an inter professional team with specialized training?
Chikdren with D
Adolescents and emerging adults with type 1 transitiining to adult care
Type 1
Women with diabetes who want to conceive or those with GD
Which individulas MAY be considered for referral to a team with specialized training?
Type 2 who consiatently not meeting cardiometabolic targets.
Those with depression + D
