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Initiatives > Chronic Care Management


Chronic Care Management (CCM): CCM interventions use electronic medical records and established care management standards and protocols to deliver effective, evidence-based care for patients with diabetes and cardiovascular disease. Areas of focus include:

  • Care Management and Care Team Strategies: The use of Care Teams and Care Managers in primary care practices to provide appropriate and targeted evidence-based care management activities designed to more effectively and efficiently care for patients with CVD and diabetes.
  • Population-based Disease Registry: Use of disease registries based on universally adopted defined populations of patients with chronic diseases. A disease registry contains data on patients with a specific type of disease diagnosed and treated at a practice, which allows care team members to proactively manage patients with chronic diseases.
  • Risk Stratification: Risk stratification enables appropriate and targeted evidence-based chronic care management activities used by Care Team members to more effectively and efficiently care for patients with diabetes and CVD.
  • Computerized Clinical Decision Support: Adopt and implement clinical decision support tools for use by care teams to more effectively manage patients with diabetes and CVD within community-based primary care settings. Standard computerized clinical decision support tools include: automated patient-centered medication action plans and care plans, flow sheets, standing orders, automated alerts and reminders, medications management and e-Prescribing, and embedded evidence-based guidelines and protocols.

The implementation of Chronic Care Management and Transitions of Care interventions are supported by the following CCBC initiatives:

  • Primary Care Development Corporation (PCDC) Practice Coaching and Learning Collaborative: CCBC has engaged PCDC, which throughout 2012 is providing hands-on practice coaching and implementing learning collaboratives with 18 primary care practices. The PCDC practice coaches, in conjunction with members of the CCBC Clinical QI Team, are working with practices on an individual basis to implement the chronic care management interventions in a manner tailored to the specific needs, resources, and structure of individual practices. In addition, PCDC is conducting five learning sessions that focus on the following topics: QI Foundation, Care Management Frame work, Clinical Decision Support, Process Workflow Redesign, Sustainability and Spread. The PCDC practice coaching and learning sessions are also closely aligned with the implementation of the TOC interventions.
  • HIT Use Optimization Efforts:  (1) Facilitation of NCQA Patient-centered Medical Home certification and Meaningful Use Stage 1-related EMR enhancement development; and (2) Facilitation of EMR functionality and configuration developments, associated workflow mapping and redesign to optimize primary care practice use of ED/Inpatient Notification and Electronic Specialty Care Referral information.
  • QI Funding Subaward Program: The goal of this program is to increase capacity and capabilities to enable direct allocation of resources by CCBC partner primary care practices and hospitals to engage in quality improvement activities that support the CCBC goals and interventions.
  • Greater New Orleans Health Information Exchange: The Greater New Orleans Health InformationExchange (GNOHIE) is a community-shared HIT infrastructure that will facilitate care coordination and chronic disease management by enhancing information and process linkages across health systems and improving the quality of care at the population level.

The CCM initiative is being developed and piloted at three providers in New Orleans:  Daughters of Charity, NO/AIDS Task Force, and Tulane Community Health Center.