An American Indian Community Implements the Chronic Care Model

Abstract

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.

Results indicate that community-initiated implementation of the CCM can be an effective strategy for creating a comprehensive community-clinical system of care for community members with diabetes. Overall, by the fourth implementation year, approximately 25% of Tribal members with diabetes had participated in the program and 28% of people on the Diabetes Registry had HbA1c levels above 9.0 compared to 32% before the Wind River ARDD program.

The success of the Wind River program suggests that community-driven approaches are a valuable strategy in our nation’s efforts to eliminate health disparities and ensure equal and fair access to quality health care for all citizens.