The Innovative Care for Chronic Conditions Framework In 2002, the ICCC Framework was introduced

by the World Health 33 Organization (WHO) in an effort to adapt the CCM for policy development
and health care system redesign from a global perspective, with special consideration for developing
countries. The framework was the result of collaborative efforts of the WHO, health leaders from
Africa, Asia, Eastern Europe, Latin America, the MacColl Institute for Healthcare Innovation, and
Edward Wagner seeking to revise and expand the CCM in response to the dramatic increase in
chronic illnesses, globally, and the need to help countries develop their health care systems
accordingly (Epping-Jordan et al., 2004; WHO 2002). The ICCC Framework is conceptually linked to
the CCM, however, unlike the CCM, it places emphasis on different aspects of what is considered to
be "good" care for chronic illnesses. That is, it emphasizes the role of community and of policy for
improving care while also emphasizing the role patients and their families as "health producers" and
recognizing that chronic illnesses may be most effectively managed with the support of their
community and their health care teams (WHO 2002; Epping-Jordan et al., 2004). See Figure 2 below.

This change in emphasis places the relationships between patients and their families, the health care
team, and community partners at the center of the care process, whereby the CCM dyad (e.g.
patients and health care team) becomes the ICCC triad and subsequently comprises the "micro-
level" that is influenced by both the overall organization of health care and the broader policy
environment and it is the “micro-level” that this study is most concerned with, thus much of the
ensuing discussion will be directed toward providing a more concise 34 Figure 2. The Innovative Care
for Chronic Conditions Framework account of the “micro-level” rather than the entire framework.
See Figure 3 below. By incorporating the community in the health care provision and management
processes, there is a greater recognition of the role that community leaders and caregivers can
provide for improving how care is accessed and provided within the community. In order for this
transformation to be successful, however, there is also an emphasis placed on each member of the
ICCC triad being informed, motivated, and prepared; thus enhanced levels of integration are
necessary for all members of this partnership to communicate and collaborate efficiently and 35
Figure 3. ICCC Triad effectively (WHO 2002). While incorporating and emphasizing the potential role
for community partners presents a significant transformation of the CCM to the ICCC Framework,
one of the, arguably, most significant changes is the expansion and recognition of the need for
patients and families to be more than “informed and activated” but to be “informed, motivated, and
prepared.” This suggests that it is not enough for patients and families to be “activated” but they
must also have adequate access to the essential medication and medical equipment, selfmonitoring
tools, as well as self-management skills. That is, as the WHO (2002) suggests, patients need to be
informed about their health condition and any chronic illnesses they have, such as diabetes.
However, they must also be 36 informed about the expected course of treatment, management and
potential progression of the illness, along with any expected complications they may encounter. In
addition, patients need to know what effective strategies are available for preventing complications
and managing symptoms. Patients also need the motivation: to change and maintain health
behaviors; to adhere to longterm therapies; and to self-manage their illness. Instrumental to this is
the realization and understanding that patients and families must also be prepared with behavioral
understanding and skills to effectively manage their illnesses at home. However, in order to do so,
patients and families must also have access to the necessary care, medications and medical
equipment, as well as the selfmonitoring tools and self-management skills to ensure that optimum
health outcomes are possible (WHO 2002, Epping-Jordan et al, 2004). Along with need for patients
and families to be more than just “activated,” the ICCC Framework emphasizes the critical need for
the health care team to be more than just “prepared” from a professional standpoint. It suggests
that the health care team needs to “informed and motivated” as well, requiring a greater degree of
integration, collaboration, and accountability to accept the roles and responsibilities for the tasks
inherent within their professional strengths and capacities. However, in doing this, each team
member must be willing to recognize the need for a flattened hierarchy within the care provision
processes as well as accepting that there must be a transition away from physician dominated
models, whereby each team member is valued for their unique 37 contribution to the management
of chronic illnesses (WHO 2002).

As described previously, a major transformation from the CCM to the ICCC Framework is the
inclusion of community partners. The emphasis upon inclusion and integration of the community by
ICCC Framework recognizes and reflects the significant roles that communities undertake in many
developing countries concerning public health and economic development issues. This emphasis on
being “prepared, informed, and motivated’ community partners suggests that in order for this
inclusion to be effective, community partners must be equipped with the information and skills that
are essential for successfully managing chronic illnesses. It recognizes that they provide an
“untapped collection of individuals” that can complement and support the care that is provided by
the broader health care organization and thus may be able to reduce unnecessary demands for
tertiary care or follow-up and monitoring services that in many countries are typically provided by an
already over-extended formal health care organization (WHO 2002). That is, community partners
can provide a critical bridge in the gap that often exists between the more formal organized clinical
care and the real world challenges faced by patients and their families (Epping-Jordan et al., 2004).

The ICCCF was chosen as it incorporates important concepts, theories and models that can be
leveraged to study the health situation of communities around the globe and the data generated can
inform the development of strategies to improve the public health of these communities that are
appropriate at the 38 community level. Such an application is appropriate, in that it is my hope and
intention that the results generated from this research project be used by the community to inform
the design and implementation of strategies aimed at improving the care and treatment of people
with diabetes and other chronic diseases across the continuum of care (e.g. prevention, diagnosis,
treatment, management). The ICCC Framework provides a guide for the organization of care for
treating and managing chronic conditions within the context of the challenges faced within many
developing economies, such as Mexico. However, the ICCC Framework is limited in its ability to
further explain actual mechanisms at work in trying to link broad population based and public health
interventions, and more critically within the dynamic relationships at the micro-level of the ICCC
triad of the health care team, patients and families, and community partners. In order to address
this shortcoming, especially regarding the ICCC triad, this study examined the perceptions and
experiences of each element of the triad using Social Capital Theory