Expanding the chronic care framework to improve diabetes management: the REACH case study

Reducing the burden of chronic conditions among minorities requires novel approaches to prevent and manage disease.

This paper describes the expansion of the Chronic Care Model (CCM) to include a community focus for improving diabetes self-management and reducing health disparities.

The literature review assesses the concept of "community" in improving outcomes as viewed by proponents of the CCM for chronic disease. The CCM was then modified and informed by experiences of a major community-based participatory action initiative to improve diabetes outcomes, the Racial and Ethnic Approaches to Community Health (REACH) Charleston and Georgetown Diabetes Coalition.

Based on our experiences with community-based and health systems diabetes interventions, we present examples of improvements within both health delivery practice sites and other community systems that are essential for improving diabetes outcomes and reducing disparities. Building on the Centers for Disease Control and Prevention's (CDC) principles of community involvement, our coalition activities provide examples of working with community partners to frame this enhanced ecologically grounded Community CCM (CCCM).

The resulting CCCM integrates expanded conceptual frameworks, evidence-based practice, community-based evidence and participatory actions, and highlights the possibilities and challenges for improving chronic disease outcomes and reducing disparities via community programs that foster individual, systems, community, and policy change.