You have completed this module and should now be able to:

Identify common medical, lifestyle and behavioral Multiple Chronic Conditions (MCC)
Conduct MCC screening, assessment, and treatment planning
Describe patient engagement, shared decision-making, and condition self-management for MCCs

The following references and resources appear in this module. The links will open in a new window.

References

Buffel du Vaure et al., Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis. BMJ Open 2016;6:e010119. doi: 10.1136/bmjopen-2015-010119

Glasgow et al., Conducting rapid, relevant research: Lessons learned from the My Own Health Report Project. Am J Prev Med 2014;47(2):212-219

Katon et. Al., Cost-effectiveness of a multicondition collaborative care intervention. Arch Gen Psych. 2012; 69:5, 506-514

Ratzliff, A., Unutzer, J., Katon, W., & Stephens, K. Integrated care: creating effective mental and primary health care teams. Hoboken, NJ:Wiley, 2016.

Wallace et al., Managing patients with multimorbidity in primary care. BMJ 2015;350:h176 doi: 10.1136/bmj.h176

Resources:

Applies the 5 A’s to a wide range of behavioral health conditions common in primary care - Hunter C., et al., Integrated behavioral health in primary care: Step-by-step assessment and intervention. Washington, DC:American Psychological Association. 2009.

Applies 5 A’s to improving chronic illness based on self-management - The 5 A’s Behavior Change Model Adapted for Self-Management Support Improvement

http://www.improvingchroniccare.org/downloads/3.5_5_as_behaviior_change_model.pdf

Medicare Learning Network: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

American College of Physicians CHRONIC CARE MANAGEMENT TOOL KIT What Practices Need to Do to Implement and Bill CCM Codes: https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf

U.S. Dept. of Health and Human Services Initiative on Multiple Chronic Conditions: http://www.hhs.gov/ash/initiatives/mcc/

AHRQ MCC Research Network: http://www.ahrq.gov/professionals/prevention-chronic-care/decision/mcc/index.html

YouTube Resource: Multimorbidity - the latest disease challenge by Professor Gerard Anderson, Director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health https://youtu.be/tvcDn-tf5uU?list=PLjlaMYL1Y8qw0FHYYuuTWkWkV2h-Y-WC

COINCIDE Patient Manual http://www.bmj.com/content/bmj/suppl/2015/02/16/bmj.h638.DC1/covp022174.ww1_default.pdf

COINCIDE Workbook http://www.bmj.com/content/bmj/suppl/2015/02/16/bmj.h638.DC1/covp022174.ww2_default.pdf

Clinician Manual http://www.bmj.com/content/bmj/suppl/2015/02/16/bmj.h638.DC1/covp022174.ww3_default.pdf