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Guiding Frameworks and Conceptual Model

SEA-CEED interventions are organized as 3 components (health organizations, other community organizations, and coalition advocacy) with a focus on systems, economic access, education and policy change.

Guiding frameworks and Conceptual Model: The ecological framework links population health to individual, community, and environmental factors. Consonant with the ecological framework is our guiding conceptual model for intervention. Our model integrates the Community Assets2 and Chronic Care Model (CCM)3,4 and expands to explicate component parts for community and resource systems. (See Figure E.1) The community systems wheel5 identifies and categorizes different community organizations that can potentially influence program outcomes.  Adapting the CCM components to both health delivery organizations and other community organizations provides a common working framework to become more prepared and proactive for improving health.

The 4 component strategies are:

  1. information systems include performance data related to desired outcomes, information to assist education, care management and serve as a rationale for systems and policy changes.
  2. delivery system design defines the team, their roles, methods for delivery, and changes that may improve the system related to delivery of services to clients.
  3. decision support includes guidelines for HCPs such as ADA Clinical Recommendations for care, education and continuing education of providers and change agents, and expert support.
  4. patient self management support includes education and activation, assessment of assets and resources for self-management, collaboration on decisions, and guidelines for clients.

The interaction of prepared proactive health and community organizations in Coalitions, catalyzed by identified change agents with state, regional, and national groups in partnership with people at risk and with diabetes will improve policies and community-wide outcomes. This will occur by balancing community action with good science. 

Click to enlarge image

* For permission to use, contact: Carolyn Jenkins, DrPH, APRN-BC-ADM, RD, FAAN (model developer) email


  1. Institute of Medicine (2000) Promoting Health: Intervention strategies from social and behavioral research, Washington DC: National Academy Press.
  2. Kretzmann, JP and McKnight, JL. (1993) Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets, Evanston, IL: Institute for Policy Research.
  3. Wagner EH, Austin BT, Davis C, et al. (2001) Improving chronic illness care: translating evidence into action. Health Affairs (Millwood) 20:64-78.
  4. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S.   (2003) The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp Q. 7(1):73-82.
  5. Anderson, ET, McFarlane, J. (2000) Community as partner: Theory and practice in nursing. Philadelphia: Lippincott.

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