The Chronic Care Professional (CCP) Program
| Module 1: Evaluating Health Care Performance | Learning Objectives |
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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, CCA, and McColl Institute (CCM Model). Describe examples of promising payer, health system, and physician practice performance improvement solutions. |
| Module 2: Population Health Improvement Solutions | Learning Objectives |
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Wellness & Disease Prevention
Disease Management
Case Management
Health Improvement Foundations
Outcomes Measures and Standards |
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 CCA 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. Describe examples of promising payer, health system, and physician practice performance improvement solutions. |
| Module 3: Chronic Diseases & Age-Related Conditions | Learning Objectives |
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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 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 |
| Module 4: The Partnership Model of Care | Learning Objectives |
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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 |
| Module 5: Health Behavior Change Facilitation | Learning Objectives |
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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. Define the spirit and four guiding principles of motivational interviewing (MI) practice. Describe the critical roles of ambivalence and resistance in the MI behavior change facilitation encounter. Self-assess professional patient care style, apply the MI-based OARs communication steps, and identify and respond to change talk. Apply a brief, five-step motivational interviewing & health coaching protocol to support patient engagement and facilitate behavior change |
| Module 6: Health Promotion and Coaching | Learning Objectives |
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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. |
