Operationalizing the Chronic Care Model with Goal-Oriented Care
Bibliographic record
Abstract
The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.011 | 0.010 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.002 | 0.011 |
| Scholarly communication | 0.007 | 0.006 |
| Open science | 0.002 | 0.006 |
| Research integrity | 0.002 | 0.004 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".