Table 1

A priori codes identified from the CCM

CCM elementsChange conceptsCodes
Health systems
Create a culture, organisation and mechanisms that promote safe, high-quality healthcare
Leadership motivated to make improvements and handle errors systematicallyOrganisational culture for safety and quality
Self-management support
Empower and prepare patients to manage their health and healthcare
Self-management support strategies to enable goal setting, action planning and regular follow-up emphasising patients’ central roleSupport for self-management
Delivery system design
Assure effective, efficient clinical care and self-management support
Clearly define roles and distribution of tasks among the healthcare team for planned interactionsPlanned interactions based on defined roles of team
Decision support
Promote clinical care consistent with scientific evidence and patients’ preferences
Enable use of evidence-based guidelines through provider educationGuidelines and provider education
Clinical information systems for individual care plan
Organise patient and population data to facilitate efficient and effective care
Provide timely reminders for follow-up and identify high-risk patients for appropriate actionFollow-up care
Community resources and policies
Mobilise community resources to support patients
Form partnerships with community organisations to support and fill gaps in health service provisionCommunity linkages
  • CCM, chronic care model.