A Chronic Care Management Framework Bridging Clinic, Home, and Community Care in a Mexican American Population

Despite evidence that chronic care management improves outcomes, a framework designed for low income, uninsured populations is still needed to improve health disparities and guide further replication. We describe the Innovative Care for Chronic Conditions framework implemented by a coalition of clinics and agencies to address chronic care management for Mexican Americans with Type 2 diabetes mellitus who have low income and primarily uninsured. The core elements of the framework are described by clinic, home and community settings with community health workers playing an essential role in the delivery of community-based services that address the social determinants of health. Promising results are described. This framework expands the understanding of chronic care management approaches and contributes to further replication of the framework in diverse settings.