Health Services We Fund

Chronic Care Management (CCM)

Since 2000, the CCM programme has been leading the way nationally in the area of managing people with chronic disease. From a population base of 440,000, there are now approximately 11,000 people enrolled on the programme, and 79% of general practices now actively participate in the Chronic Care Management Programme. CCM also targets the high needs population. 70% of people enrolled in CCM defined as Maori and Pacific.

The programme is based on the Chronic Care model developed by Ed Wagner. It is designed to support patients with chronic conditions in the community where they can be followed up on a regular basis throughout each year.

The programme gives patients with a chronic condition the opportunity to work with their general practice team to help improve the management of their condition.

At the highest level, it involves the identification of patients at GP practice level, with specific long term conditions.

The CCM programme delivers a continuum of care by integrating various services. CCM helps facilitate changing provider behaviour from acute episodic care to structured case management. This is done via

Structured notes which are embedded within practice computer software

Empowering primary care by :
- Secondary outreach/training
- Electronic decision support
- Regular reporting on progress

A broader aim of the scheme is to educate not only the individual but the whole family. The philosophy being that to help an individual make lifestyle changes then you must help the family make changes too.

The CCM programme currently includes five modules: Diabetes, Congestive heart failure (CHF), Respiratory Disease (COPD), Cardio-vascular Disease (CVD), a catch all category of "Other" which includes Frequent Adult Medical Admissions (FAMA) and the pilot module of Depression.

Chronic Care Management Plan - 2001 -2006

Published: 06-Jul-2011 | Website enquiries: Web Content Manager