Nursing Capstone – Chronic Care Model
The Chronic Care Model is an evidence-based framework that was developed to help improve chronic illness care. It contains 6 core elements:
Community Resources and Policies – Developing partnerships with community organizations to support healthy behaviors and address gaps in services. This could involve assessing available resources and developing new partnerships in the community.
Health System Organization – Ensuring care is coordinated within the health system across different teams and levels. This involves examining current care coordination processes and recommending improvements to facilitate coordinated care.
Self-Management Support – Empowering patients to manage their conditions through education, collaborative goal-setting, and problem-solving support. This could involve developing a new group education program, individual patient coaching program, or online patient portal.
Delivery System Design – Structuring provider roles and responsibilities to match chronic care needs. This may involve developing new protocols or care pathways for chronic condition management, evaluating provider roles and capacity, and recommending improvements to meet patient needs.
Decision Support – Guiding provider decisions with evidence-based guidelines and clinical information tools. This could involve developing a clinical guideline or protocol for a specific condition, designing a decision support tool embedded in the EHR, or evaluating current practices against evidence-based guidelines.
Clinical Information Systems – Optimizing care through use of registries, information sharing, and patient/population health monitoring. Projects may involve designing and implementing a new registry within the EHR to monitor outcomes, automate reminders, or stratify patients for outreach.
The Chronic Care Model provides a comprehensive framework to evaluate how an organization currently supports chronic disease management and identify areas of improvement across different levels of the healthcare system. A capstone project could leverage this model to assess one or more elements and make recommendations to strengthen chronic illness care.