title: Home-based chronic care. An expanded integrative model for home health professionals.
abstract: The Chronic Care Model (CCM) developed by is an influential and accepted guide for the care of patients with chronic disease. Wagner acknowledges a current healthcare focus on acute care needs that often circumvents chronic care coordination. He identifies the need for a "division of labor" to assist the primary care physician with this neglected function. This article posits that the role of chronic care coordination assistance and disease management fits within the purview of home healthcare and should be central to home health chronic care delivery. An expanded Home-Based Chronic Care Model (HBCCM) is described that builds on Wagner's model and integrates salient theories from fields beyond medicine. The expanded model maximizes the potential for disease self-management success and is intended to provide a foundation for home health's integral role in chronic disease management.
authors.affiliation: Chronic Care, Baptist Health Home Health and Hospice, Little Rock, AR 72210, USA. paula.suter@baptist-health.org
authors.forename: Paula
authors.initials: P
authors.lastname: Suter
authors.forename: Beth
authors.initials: B
authors.lastname: Hennessey
authors.forename: Gregory
authors.initials: G
authors.lastname: Harrison
authors.forename: Martha
authors.initials: M
authors.lastname: Fagan
authors.forename: Barbara
authors.initials: B
authors.lastname: Norman
authors.forename: W Newton
authors.initials: WN
authors.lastname: Suter
mesh_terms: D019090:Case Management / Q000458:organization & administration; D002908:Chronic Disease / Q000451:nursing*; D003152:Community Health Nursing / Q000458:organization & administration*; D003362:Cost-Benefit Analysis; D020000:Decision Support Systems, Clinical; D019468:Disease Management; D006301:Health Services Needs and Demand; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D007857:Leadership; D008134:Long-Term Care / Q000458:organization & administration*; D016347:Medical Records Systems, Computerized; D016294:Models, Nursing; D017146:Models, Organizational; D024802:Nurse's Role; D010821:Physicians, Family / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration; D012648:Self Care; D017749:Total Quality Management / Q000458:organization & administration