An American Indian Community Implements the Chronic Care Model: Evolution and Lessons Learned

摘要

The chronic care model (CCM) has been initiated most frequently in clinical settings with outreach to the community to obtain involvement and guidance. Implementation of the CCM by communities that reach out to clinicians and develop linkages and coordination to improve care for community members with chronic conditions is less frequently observed. This commentary describes the implementation of the CCM by the Eastern Shoshone Tribe of the Wind River Indian Reservation. The design emphasized community-based leadership, with the Tribe having the primary role in developing and implementing culturally tailored community self-management supports, improving linkages with Indian Health Service (IHS) clinicians and cultural knowledge of providers, and developing a coalition of organizations with additional resources to create a more comprehensive system of diabetes care for Tribal members with diabetes.