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Table 1 Examples of operationalization of the CCM

From: Partnering with health system operations leadership to develop a controlled implementation trial

CCM goal: anticipatory, continuous, evidence-based, collaborative care via…
Work role redesign Self-management support for individuals in treatment Decision support Information management Community linkages
• Care management
• Access-driven scheduling
• Activated follow-up
• Incorporation of the individual’s values and skills
• Shared decision-making
• Self-management skiIIs
• Behavioral change interventions
• Provider education
• Practice guidelines
• Specialty consultation
Population: registry
Provider: reminders
• Outcome tracking
• Feedback
• Integrated care plans
• Additional resources
• Peer-based support
Organizational leadership and support