The Chronic Care Model (CCM) emphasizes the fact that improved functional and clinical outcomes are the direct product of an informed, activated patient
, and a prepared, proactive practice team. The CCM’s primary practice-based components include: encouraging patients to engage in the management of their own healthcare and providing them with the resources and skills to obtain appropriate healthcare services; designing a delivery system to assure the provision of effective, efficient clinical care services; embedding clinical decision support tools into daily practice; and using information technology to support patient education, care planning and coordination, and the monitoring of performance. The system level attributes of the CCM that create a culture of safe and high-quality healthcare include the use of community resources, partnerships, and policies that support and organize the healthcare system. These elements of the CCM are vital to a healthcare delivery system that supports the economic viability of a practice’s structure.

The advanced medical home acknowledges that the best quality of care is not provided in episodic, illness oriented, complaint based healthcare, but, rather, through patient centered, physician guided, cost efficient, longitudinal healthcare that encompasses and values both the art and science of medicine. Advanced medical home practices provide a range of options for physicians and patients that support their personal health goals (e.g., health education, nutrition services, disease management) either directly or through established relationships with external providers of these services such as disease management companies. The patient, with support from the physician and other members of the healthcare team such as nurses, social workers, care managers, dietitians, pharmacists, physical and occupational therapists, and other allied healthcare professionals, then become engaged in his/her healthcare. In return, the healthcare system better serves the individual needs of each patient.

A diversified patient population is the sustainable model of the future for community health clinics. Administering a level of service that meets the standards of both insured and uninsured patients helps to transition a community clinic into a viable service center. This objective is accomplished through quality assurance efforts, workforce education, and clinical standards measures. Crafting a panel of Key Quality Assurance Indicators will provide measures to gauge, evaluate, and ensure the progress of community health clinics.