Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Characteristics of the Chronic Care Model

DESCRIPTION OF THE COMPONENTS OF THE CHRONIC CARE MODEL

Component
Description
Example
Self-Management Support/
Develop Personal Skills
Enhancing skills and capacities for personal health and wellness
Smoking prevention and cessation programs; RNAO BPG
Seniors walking programs
Decision Support
Integration of strategies for facilitating the community’s abilities to stay healthy
Development of health promotion and prevention “best practice” guidelines
 
Utilization of decision support tools
Delivery System Design
Re-orient Health Services
Expansion of mandate to support individuals and communities in a more holistic way
Advocacy with, and on behalf of vulnerable populations
 
Emphasis on quality improvement and health and quality of life outcomes, as well as clinical outcomes
Clinical Information Systems
Creation of broadly based information systems to include community data reflecting the determinants of health
Use of broad community needs assessment that take into account
indicators such as:
Poverty rates
Availability of public transportation
Violent crime rate
Informed, Activated Individuals and Families
The individual understands their chronic health condition, and has assumed the role of self-manager for their care. Family and friends are engaged in the individual’s self management process
Consults with health-care provider as a guide; develops goals and self-care plan that includes family/friends
Prepared, Proactive Practice Team
Establish care for chronic health conditions as a priority among all team members
Develop self-management goals and tools to be implemented in a collaborative way with the client, family and health team members
Community Resources and Policies
Working with the community groups to set priorities and achieve goals that enhance the health of the community
Maintaining older people in their homes for as long as possible
Senior centres, and self-help groups

Stages of Change Model

STAGE IN TRANSTHEORETICAL MODEL OF CHANGE
PATIENT STAGE
Precontemplation
  • Not thinking about change
  • May be resigned
  • Feeling of no control
  • Denial: does not believe it applies to self
  • Believes consequences are not serious
Contemplation
Weighing benefits and costs of behavior, proposed change
Preparation
Experimenting with small changes
Action
Taking a definitive action to change
Maintenance Maintaining
Maintaining new behavior over time
Relapse
  • Experiencing normal part of process of change
  • Usually feels demoralized

Adapted from Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992) In search of how people change. Am Psychol .47:1102-4, and Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.