The National Chronic Care Consortium's step-by-step regimen for integrating care of the chronically ill is centered around nine objectives that represent the critical dimensions for chronic-care network development. When the Self-Assessment for Systems Integration developmental tools are successfully implemented:
Governance structures support goal development and improve the ability of care providers to work together as a single system.
Management strategies and structures support integration efforts across sites and disciplines.
Information technology systems allow providers in all settings to share meaningful information about clients, costs and operations.
Financing systems promote systemwide management of cumulative costs, tied to care outcomes.
The needs of high-risk populations are identified.
A full array of effective and efficient services is provided.
Care management is focused on disability prevention and organized around defined populations-for example, high-risk categories or those with a specific condition such as diabetes.
Seamless care is provided across settings and over time.
Clients are involved in care management and initiatives to help them care for themselves.
The SASI development tool has four sections:
Guidelines and indicators
Rather than list ready-made indicators on various chronic illnesses, the section includes an outline for coming up with internal guidelines and measures depending on a network's specific target populations and its objectives. The outlines help develop implementation strategies and a set of operational activities to measure progress.
Planners assess their progress on worksheets for each of the program's nine objectives. For each objective, the worksheet asks for progress achieved, major barriers to making progress, steps to improve in the next year, and who will be responsible for overseeing progress.
The brief survey asks chronic-care networks how well they're progressing along key measures of chronic-care integration. The answers are intended to be fairly quantitative, providing periodic "snapshots" of progress.
Selected articles and other resources such as manuals, books, conferences and tools offer more background on the program's objectives.
Source: National Chronic Care Consortium