The CCM includes the features of a health care system that encourage high-quality care. These features fall into six components: SM support, delivery system design, decision support, clinical information systems, health care organization, and community resources31,32
. When put together, they limn the contours of productive interactions between informed, activated patients on the one hand, and well-prepared, proactive practice teams on the other.
Patients' SM needs are met through productive interactions between patients and families and their practice team. By “productive” we mean that patients' needs and goals are systematically and consistently addressed to develop mutually determined care plans. Productive interactions are more likely to occur when patients actively participate and are invested in their own care and are competent, confident managers of their health and illness. To be competent and confident managers, patients must have the relevant information and skills to set priorities and manage their illness.
Enabled and empowered patients
Patients who have the relevant information, skills, and the confidence to engage in SM interventions are enabled33
. Interventions that encourage patients to be involved in their own care enable patients. Such enabling interventions are those through which collaboratively patients and providers identify goals that are important to patients, develop realistic action plans to meet those goals, and identify aspects of the plans that patients can self-manage.
Patients whose concerns, priorities and resources are considered important enough to be included in the plan of care are empowered34
. Time-limited courses facilitated by peer or professional leaders and focused on empowering patients to manage their own illness have been shown to improve disease control35,36
. However, sustained support focused on assisting patients in managing their own illnesses may be optimal37
. Such support is most efficiently provided in the context of ongoing chronic-illness care.
Ongoing advice and encouragement from the practice team are important in order to enable and empower patients. Yet many clinicians have neither the time nor the expertise necessary to train and counsel patients effectively. In cancer care, several randomized trials have demonstrated that clinicians with good communication skills and additional training in counseling methods, methods such Motivational Interviewing (MI) or Cognitive Behavioral Therapy (CBT), perform these functions well16,17
. More recent evidence suggests that individuals with limited clinical training can also be trained to provide the support necessary to enable and empower patients to participate in SM38
Another way to enable and empower patients is to use community-based programs and organizations, which often most effectively meet many of the needs of chronically ill patients. Such needs include: transportation, homemaker services, smoking cessation, exercise, weight control, peer support, caregiver support and respite care, self-management training, financial counseling and assistance. Many clinical practices, however, do not have enough time and information to assist patients with such services. For commonly needed services, practices should at least have the information necessary to advise patients on best options, and to make referrals to and initiate connections with other service providers. For critical services, practices might consider developing partnerships with community-based organizations that can access for patients the services that will be of value to them.
Enabled and empowered patients—patients with the skills, information, and community-based resources necessary to tackle problems related to the care of their chronic illness—are partners in productive interactions. They are not alone, however. The other partners are the primary practice teams.
Proactive and prepared practice teams
Practice teams must be prepared and proactive if they are going to see major improvements in chronic illness performance measures. Prepared practice teams integrate evidence-based reminders into the flow of clinical decision-making. They review key patient information before visits and review patients' goals during visits to determine what services are needed and to develop mutually determined care plans. They use clear task assignments and standing orders to ensure the delivery of those services, and they have the necessary trained staff.
Effective chronic-care management also depends on careful and proactive follow-up by practice teams—follow-up tailored to each patient's disease severity and preferences. Chronically ill patients at higher risk of emergency room use, hospitalization, or major complications have been shown to benefit from more intensive follow-up and clinical management by a care manager. Clinical care management, generally provided by a health care professional such as a nurse or clinical pharmacist, includes clinical assessment, medication management, self-management support, and care coordination28,39-44
, including among post-surgical cancer patients14,15,45
Efforts to improve cancer care must address the realities of the fragmentation of care—that is, of not knowing just which provider is accountable for the whole picture of what is often complex treatment. The disease itself may increase patients' distress, but this fragmentation of care adds to it. Therefore, efforts to improve cancer care must address the quality and the coordination of all the medical practices and providers involved in patients' care. The CCM is a model that oncology practices can adopt to address the quality and the coordination of all the medical practices and providers involved in patients' care.
A practice home for patients with cancer
The most effective cancer care requires a practice home for each patient. This home is the one practice team that holds itself accountable to patients; it is the practice team that takes on the responsibility of guiding and supporting patients along the cancer-care continuum, a continuum that is not straight, but rather, labyrinthine. While this labyrinth begins with diagnosis, its circuitous path leads from staging to treatment planning, from treatment planning to treatment, and from treatment back to staging; if staging suggests progression, the path leads back to treatment planning again. Patients walk along this circular labyrinth as survivors. Given this complexity, the linear sharing of information across providers or the mere holding of tumor boards will unlikely satisfy patients' needs. The CCM's notion of a practice home, however, offers a model to facilitate centralized, consistent care.
The CCM's notion of a practice home may, at first glance, give the impression that primary care providers PCPs must be the practice home of cancer patients. While it is true that PCPs must play a major role in coordinating care, PCPs often feel as if they do not have enough information to answer cancer patients' questions. Oncology providers can serve as the practice home—if patients were referred to oncology immediately upon suspicion or diagnosis. Through coordination of care with PCPs, oncology providers can ensure that patients' general preventative needs are met and co-morbid conditions well-managed. A care manager or coach that links PCPs and oncology providers can help patients navigate the early phases of care, and provide information, skills training, emotional support, among other services. This care manager (a patient champion, as it were) ensures optimal care on patients' journey along the twists and turns of the cancer-care continuum. This champion embodies for patients the cancer care system; as such, this champion holds him- or herself accountable for a patient's entire journey on the cancer-care continuum.
Collaborative care plans
The task of being patients' champions—of being, that is, their practice home—may seem impossible. It is not. Developing and maintaining care plans make it possible. The 2005 IOM report emphasized the importance of explicit care plans1
. Care plans form the bond that holds together the partnership between patients and practice teams, but they must be mutually determined. Care plans developed collaboratively with patients make for informed and enabled patients, and they contribute to better coordination of care. The development of a collaborative care plan should be an integral part of the work of the home practice team, and subsequent providers must continue the process to keep the plan current.
We have expounded upon the CCM and applied it to the problem of providing care to cancer patients, care that involves the complexities and nuances of chronic illnesses. We have suggested that oncology practice teams serve as the practice home for cancer patients. We have also suggested that the CCM's notion of productive interactions holds true between cancer patients and oncology practice teams. Oncology practice teams can enable and empower cancer patients to arrive at multi-disciplinary, collaborative care plans that serve as guides for SM interventions along the cancer-care continuum—for patients and oncology practice teams alike. SM interventions are fundamental to enabling and empowering patients so they can take care of themselves along the cancer-care continuum in the way they prefer. We now highlight current applications of successful SM clinical programs in cancer care in which components of the CCM are used.