Care Model

The Care Model© has been utilized by community health clinics for several years as an effective method of providing comprehensive, efficient, team based health care.  This tool kit was designed to provide easily accessible, user friendly resources to assist you in implementing the Care Model into practice.  The resources listed are not an exhaustive list, but rather a sampling of forms, tools, power point presentations, articles and training courses, all available on-line, to help implement the Care Model.  These tools can be used for orientation and training of staff and be implemented into practice policy and program development. There are many available examples of best practices and programs developed using the Care Model framework.

Care Model Presentation

1. Community Resource Documents This section highlights building community connections, assessing community needs, and planning community based programs through the utilization of existing community resources, formation of partnerships with community-based organizations, and advocating for improvements in services and policies for patients.
2. Health Systems, Organization of Care: Create a Culture, Organization and Mechanisms that Promote Safe, High Quality Care focuses on systems that promote safe, high quality care. Providers should work toward comprehensive system change, provide incentives to improve quality of care, and develop systems for coordinating care across organizations. Support from all organizational levels is required. Included in this section is the Health Disparities report and documents for readiness assessment, employee orientation, sample meeting agenda, project planning forms, and PDSA examples.
3. Self-Management Support: Empower and Prepare Patients to Manage their Health and Health Care promotes activities to empower and prepare patients to manage their health care. This component reflects the patient’s central role in care and treatment and stresses use of self-management support strategies, including assessment, goal setting, action planning, problem solving, and follow-up. This section includes self management orientation and training for staff and patients and examples of self management plans for asthma and diabetes, including Spanish language resources.
4. Delivery System Design: Assure the Delivery of Effective, Efficient Clinical Care and Self-Management Support ensures delivery of effective and efficient clinical care and self-management support. The system should promote definition of roles among the clinical care team, a structure for communication and service delivery between the team members and clients, and regular follow-up. Included in this section are examples of operational flow assessments, standing orders, planned care and group visit models.
5. Decision Support: Promote Clinical Care that is Consistent with Scientific Evidence and Patient Preferences promotes care that is consistent with scientific evidence and patient preferences. Clinical practice should reflect standard treatment guidelines. Decision support should use proven methods of provider education and integrate specialist expertise and primary care. This section includes resources for evidence based guidelines.
6. Clinical Information System: Organize Patient and Population Data to Facilitate Efficient and Effective Care should use data to facilitate effective care. Data systems monitor the performance of the care system and provide reminders for both providers and patients. Examples of PECs reporting and Health IT for data management included.