Core Competency #1: Advocate for Improved Chronic Care
Articulate the consumer and financial imperatives for improved chronic care and health care systems change.
Compare and contrast the traditional acute practice model vs. the expanded chronic care model of integrated, evidence-based, consumer-focused care.
Describe foundations and strategies of population-based care.
Overview primary care and disease management organization (DMO) models for improving chronic care outcomes.
Describe change management strategies and interventions for overcoming stakeholder resistance and facilitating organization and community change.
Overview leading chronic care/health care improvement models, e.g., the Institute of Medicine, World Health Care Organization, McColl Institute, and the Disease Management Association of America.
Describe the population-based approach to care and overview leading models for segmenting consumer populations based on risk status.
Overview health risk appraisal tools and disease/risk-based stratification approaches including patient registries and predictive modeling.
Critically evaluate health care research – and identify and apply leading evidence-based care guidelines and resources to improve care quality and efficiency.
Assess consumer needs and create disease management care plans that support consumer goals – and drive adherence with evidence-based clinical care and self-care guidelines.
Teach consumers, family members, and community chronic care partners how to advocate for evidence-based health care services.
Understand the range of consumer chronic care needs -- and support community collaboration and care coordination across the extended community chronic care team.
Describe demonstrated measurement strategies and incentives for supporting better chronic care outcomes by physicians and other health care providers.
Core Competency #3: Drive Evidence-Based Care and Self-Care for Leading Chronic Diseases and Age-Related Conditions
Educate consumers about potential impacts, complication warning signs, standards of care, and self-care steps for common chronic diseases and age-related conditions.
Promote consumer self-efficacy and independence – particularly for consumers with multiple chronic conditions, cognitive impairment, or functional deficits.
Identify and support the management of cognitive disorders that that lead to avoidable hospitalization and nursing home placement in late-life.
Employ evidence-based strategies to manage polypharmacy and support medication adherence.
Support and link older adults with long-term care and home and community based supports and public health resources to facilitate aging in place.
Identify the signs and common reversible causes of late-life frailty – and implement evidence-based steps for assessing and managing frailty.
Employ evidence-based strategies for managing at-risk mothers. Support recommended child health screening guidelines.
Core Competency #4: Create Partnerships with Consumers That Support Disease Self-Management and Facilitate Behavior Change
Support consumer quality of life, dignity, and well-being regardless of level of impairment, age, race, or ethnic background.
Facilitate two-way provider-consumer communications and forge cooperative care partnerships.
Encourage consumer engagement and shared health care decision-making.
Support consumer (and caregiver) management of psychological, social, financial, role and family impacts of chronic conditions.
Reinforce consumer independence, choice, and control in all interactions – building on strengths and abilities.
Employ consumer-centered and evidence-based strategies to promote disease self-management and positive lifestyle changes.
Identify consumer goals, explore change readiness, create change plans, and support ongoing care plan adherence. Spot and manage overt/covert consumer resistance.
Employ evidence-based behavior change readiness and behavior change facilitation interventions including motivational interviewing.
Core Competency Group #5: Promote Health and Disease Screening
Articulate the value, features, and success factors for evidence-based, integrated wellness/disease management programs.
Identify and advocate for delivery of evidence-based primary care disease screening for adults and seniors.
Support healthy dietary practices that promote disease self-management and general health.
Promote the recognition and proper management of undernutrition in seniors.
Identify the costs and health consequences of inactivity in adults and seniors. Summarize evidence-based guidelines for building endurance, strength, flexibility and balance.
Implement practical strategies for supporting daily physical activity – particularly in consumers who have been inactive.
Identify and address psychosocial factors that may influence health care and consumer outcomes. Support consumer life engagement and social connections.
Identify the costs and health consequences of obesity. Assess overweight and obese consumers – and advocate for evidence-based weight self-management and medical weight management strategies and interventions.
Core Competency # 6: Deliver Improved Value to Consumers and Payers
Describe strategies and approaches for improving the value of health care delivered to consumers.
Describe national, state and employer-purchaser public health care outcomes reporting and pay for performance strategies and programs – and detail how providers can succeed in a performance-based health care environment.
Understand and reduce unwanted variation in health care services.
Understand and apply emerging health care process improvement strategies and interventions – including six sigma.
Identify promising primary care-based models of chronic care delivery including group visits and planned health care visits.
Leverage emerging technologies including electronic health records and remote health monitoring to drive improved outcomes.
Build an integrated disease management program scorecard.
Critically evaluate DM program outcome and ROI data. Describe effective approaches for evaluating disease management program performance and ROI measurement.
