Table 4.

Mechanisms identified and their relation to the CCM: The 11 main mechanisms are in boldface.

Patient-centred interdisciplinary care
  • 1.1 Regular follow-up of patients by an interdisciplinary care team

  • 1.2 Establishment of a patient-centred intervention, adapted to patient needs

  • 1.3 Facilitated access for patients to health and social services

  • 1.4 Implementation of a change management process

  • 1.5 Adoption of a multimorbidity approach for patients with chronic disease

Delivery of system design or reorientation of health services
Self-management support and motivational approach
  • 2.1 Patients’ educational resources and skills development to support their self-management

  • 2.2 Facilitated access to physical activity for patients and their caregivers

  • 2.3 Adoption of a motivational approach

Self-management support
Professional support
  • 3.1 Training offered to professionals

  • 3.2 Adoption of evidence-based guidelines in daily clinical practice to optimize the clinical process

  • 3.3 Adoption of collective orders

Decision support
Care coordination and relationships with partners
  • 4.1 Facilitated care coordination

  • 4.2 Development and consolidation of partnerships with the partners of local health and social services

  • 4.3 Mobilized managers and decision makers

Organization of health care
Use of community resources
  • 5.1 Established and consolidated agreements with community resources

Community resources and policies
Informational continuity and clinical information system
  • 6.1 Transmission of the patient follow-up to his or her other care providers

  • 6.2 Integration of information about the intervention into the patient’s medical record

  • 6.3 Deployment of a regional register on chronic disease

Clinical information systems
Mechanisms not related to the CCM
  • 7.1 Results of the program used to carry out the restructuring of the organization

  • 7.2 Establishment of the partnership between the decision maker, researchers, and clinicians for collaborative research

  • 7.3 Establishment of governance structures for the program

  • CCM—chronic care model, NA—not applicable.