The Chronic Care Professional (CCP) Program (Fourth Edition)

Module 1: Evaluating Health Care Performance

• The Imperative
  for Change & Performance Improvement

• Health Care Improvement Solutions

• Chronic Care Improvement

• Critically evaluate US and international health care quality, consumer satisfaction, and financial performance outcomes.

• Communicate the “burning platform” for health care systems change and advocate for new organization capabilities and professional competencies.

• Describe components and features of leading health and chronic care improvement models advanced by the World Health Organization (WHO), Institute of Medicine, DMAA, and McColl Institute (CCM Model).

• Describe examples of promising payer, health system, and physician practice performance improvement solutions.

• Describe the core foundations and best practices of US and international wellness, disease management and case management programs.

• Cite industry-standard PHI resources available from DMAA and other sources.

• Overview PHI methods and interventions across the population—from patient identification though complex case management.

• Advocate for evidence-based medical care and partner with physicians.

• Engage patients in phone and face-to-face encounters.

• Describe how population health improvement programs are evaluated, common program evaluation flaws, and how professionals can support system and program performance in their day-to-day roles.

• The Big Five
  Chronic Diseases

• Key Chronic Diseases and Conditions

• Age-Related Conditions

• Issues of Late-Life

• Describe the complication Warning signs, Impacts, daily Self-care steps, and 2008-updated Evidence-based medical guidelines summaries for over 25 chronic diseases and conditions

• Apply the WISE model of disease management and disease self-management support.

• Overview key considerations for working with seniors and interventions for managing common age-related concerns including frailty, falls risk, delirium, dementia, and polypharmacy.

• Describe the value and components of advanced directives, palliative care, and compassionate and effective end-of-life care.

• Self-Care and Adherence Support

• Whole Person Care

• Health Literacy Improvement

• Cultural Competence

• Provide examples of how to transition from the traditional, acute medical model to the provider-patient shared partnership model.

• Describe key features and considerations of the “whole person” model.

• Compare and contrast the “patient education” practice model with an evidence-based treatment adherence and self-management support model.

• Identify and address common psychological issues that influence illness behavior and health behaviors.

• Overview the influence of culture and health, the problem of health disparities, and steps for working cross-culturally.

• Orientation to Health Behavior Change

• Behavior Change Models

• Behavior Change Communications

• Change Facilitation Steps

• Assess self-readiness and personal biases about behavior change facilitation— debunk the notion that “resistance” is a “patient problem.”

• Summarize the science of behavior change; evaluate the strengths and limitations of leading evidence-based health behavior change models.

• Apply a brief, five-step motivational interviewing & health coaching protocol to support patient engagement and facilitate behavior change.

• Orientation to Health Coaching

• Diet and Nutrition

• Obesity and Weight Management

• Physical Activity and Fitness

• Self-Care for Caregivers

• Describe key features & tasks of preventative and therapeutic health coaching.

• Summarize key components of healthy diet; describe and support healthy dietary choices to prevent chronic illness and support health.

• Apply evidence-based weight assessment and management interventions for weight loss; detail indications for weight loss drugs and bariatric surgery.

• Apply 2007 American College of Sports Medicine (ACSM) and American Heart Association guidelines for physical activity.

• Apply ACSM guidelines for aerobic fitness, large muscle/core strength, and balance/flexibility for healthy, chronically ill and older adult patients.

• Evaluate self-health and design a personal health improvement plan.

• Evaluate and build self-resilience and stress management skills.