Publication Date

Spring 2016

Degree Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Danette Dutra

Second Advisor

Phyllis Heintz

Third Advisor

Alpha Anders


Chronic care management toolkit


Currently, little research is available on the topic of Chronic Care Management (CCM) service and its impact on patient health outcomes, largely because the service was recently introduced by Medicare in January 2015. The purpose of this Doctor in Nursing Practice (DNP) project is to create a Chronic Care Management (CCM) Toolkit specific to an established pulmonology practice based in a Central California community. This quality improvement pilot project also included an evaluation of the newly developed CCM Toolkit designed for this project. The evaluation was accomplished by surveying CCM care team members in this pulmonary practice (an internal group), and providers who have experience in providing care in patients with chronic conditions (an external group). Both internal and external groups agreed that the toolkit could be successfully implemented in the practice and could be easily adapted to a wide variety of practice settings. In addition, both groups provided valuable recommendations for improving the toolkit. This project is the first known study on the topic of implementing the CCM service in a small independent practice. The newly developed CCM Toolkit offers a framework, and can serve as a roadmap, for practices seeking to provide CCM service to their patients with multiple chronic conditions. Future research is needed in a number of areas. Studies exploring patient satisfaction with the care received, assessing the efficiency of the care coordination, and evaluating the impact of the CCM service on patient care outcomes, such as increased quality of life, decreased exacerbation, decreased hospitalization and reduced health care cost, will generate much needed evidence on the topic of the CCM model.


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