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Background <p>Increasing numbers of people live with chronic conditions. Yet, healthcare systems are often designed based on an acute care model that is not well-aligned with the needs of patients with chronic conditions, resulting in poor patient outcomes and high healthcare costs. To better assist patients living with chronic conditions, there is an urgent need to develop chronic care management models that are effective, scalable, and financially sustainable. The aim of this study was to identify and describe key components of chronic care management practice as a foundation to develop such a program.</p> Methods <p>We conducted a qualitative descriptive study interviewing care managers who care for patients living with chronic conditions in community settings. Eleven care managers were recruited from three healthcare organizations in the U.S. Pacific Northwest using a purposive sampling method. Individual interviews were conducted between July and December 2022 using a semi-structured interview guide developed by the researchers. Audio recordings of interviews were transcribed and analyzed using a thematic analysis approach.</p> Results <p>Participants said that their practice was driven by the patient needs and tailored to their unique conditions and situations rather than to specific diagnoses. Five key components of chronic care management were: (1) whole person assessment; (2) patient-centered care planning; (3) direct care to assist patients to manage their needs; (4) care coordination; and (5) longitudinal evaluation and monitoring.</p> Conclusion <p>Findings from this study provide concrete descriptions of key components of chronic care management practice and contribute to filling gaps in the literature. Integration of these practice components in the design of chronic care management programs is a necessary next step to deliver effective chronic care. We discuss clinical and financial implications of these components, and recommend strategies and future steps to design pragmatic, effective, and financially sustainable chronic care management programs.</p>

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Key components of chronic care management programs: qualitative descriptions of care managers’ practice

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年11月22日

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  • Shigeko Izumi,
  • Laura Mood,
  • Lace Velk,
  • Courtney Szper,
  • Alexis Fifield,
  • Darcey Ayala,
  • Walter D. Dawson,
  • Dana Womack

摘要

Background

Increasing numbers of people live with chronic conditions. Yet, healthcare systems are often designed based on an acute care model that is not well-aligned with the needs of patients with chronic conditions, resulting in poor patient outcomes and high healthcare costs. To better assist patients living with chronic conditions, there is an urgent need to develop chronic care management models that are effective, scalable, and financially sustainable. The aim of this study was to identify and describe key components of chronic care management practice as a foundation to develop such a program.

Methods

We conducted a qualitative descriptive study interviewing care managers who care for patients living with chronic conditions in community settings. Eleven care managers were recruited from three healthcare organizations in the U.S. Pacific Northwest using a purposive sampling method. Individual interviews were conducted between July and December 2022 using a semi-structured interview guide developed by the researchers. Audio recordings of interviews were transcribed and analyzed using a thematic analysis approach.

Results

Participants said that their practice was driven by the patient needs and tailored to their unique conditions and situations rather than to specific diagnoses. Five key components of chronic care management were: (1) whole person assessment; (2) patient-centered care planning; (3) direct care to assist patients to manage their needs; (4) care coordination; and (5) longitudinal evaluation and monitoring.

Conclusion

Findings from this study provide concrete descriptions of key components of chronic care management practice and contribute to filling gaps in the literature. Integration of these practice components in the design of chronic care management programs is a necessary next step to deliver effective chronic care. We discuss clinical and financial implications of these components, and recommend strategies and future steps to design pragmatic, effective, and financially sustainable chronic care management programs.