Continuity of Care Maturity Model
CCMM: A strategic framework to guide continuity of care implementation
HIMSS Analytics created the international oriented Continuity of Care Maturity Model (CCMM) to promote coordinated care across the continuum of care served by a health provider or the responsibility of a health authority. With this eight stage (0-7) model, measure and understand your ability to provide continuity of care across types, settings and populations. Manage with a clear strategy for coordinated care.
Knowledge driven engagement for dynamic, multi-vendor, multi-organisational interconnected healthcare delivery model
- Comprehensive pop-health.
- Completely coordinated care across all care settings. Integrated personalised medicine.
- Near real-time care community based health record and patient profile.
- National and local policies are aligned.
Closed loop care coordination across care team members
- Dynamic intelligent patient record tracks closed loop care delivery and multiple care pathways/protocols for each patient along with patient compliance tracking.
- Organisational, pan-organisational, and community-wide Clinical Decision Support (CDS) and population health tracking.
- Policies address non-compliance.
Community-wide patient records using applied information with patient engagement focus
- Community-wide patient record with integrated care plans and bio-surveillance.
- Patient data entry, personal targets, alerts are available.
- Patient data aggregated into a single cohesive record. Mobile tech engages patients.
- Community wide identity management.
- Best clinical practices are derived from care community healthcare data and operationalised across the community (continuous quality improvement and adaptation).
Care coordination based on actionable data using a semantic interoperable patient record
- Shared care plans track, update, task coordination with alerts and reminders.
- E-prescribing. Pandemic tracking and analytics is in place.
- All care team members have access to all appropriate data.
- Semantic data drives actionable Clinical Decision Support and analytics.
- Comprehensive audit trails.
- Policies are in place for collaboration, data security, mobile device use, and interconnectivity between healthcare providers and patients.
Normalised patient record using structural interoperability
- Multiple entity clinical data integration.
- Regional/national PACS.
- Electronic referrals, consent are in place.
- Telemedicine is being used.
- Aggregated clinical and financial data.
- Medical classification and vocabulary tools are pervasive.
- Mobile tech supports point of care.
- Data governance across varied internal and external organisations is coordinated.
Patient centred clinical data using basic system-to-system exchange
- Patient record is available to multi-disciplinary internal and tethered care teams.
- EMR exchange is occurring on a limited basis. Immunisation and disease registries for all patients.
- There is a patient-centred clinical data presentation.
- Pervasive electronic automated ID management for patients, providers, and facilities.
- Policies drive clinical coordination and semantic interoperability.
- Change management process is documented and standardised.
Basic peer-to-peer data exchange
- Limited shared care plans outside the organisation.
- Leverage 3rd party reference resources.
- Basic alerts are in place.
- Some externally generated data incorporated into patient record.
- Policies for Continuity of Care strategy, business continuity, disaster recovery, and security & privacy are in place.
- Data governance is active.
Limited or no e-communication
- Engaged in EMRAM maturation.
- Data is isolated.
- Governance is informal and undocumented.