Chronic Care Model

The Chronic Care Model (CCM) is a multifaceted, evidence-based framework for enhancing care delivery by identifying essential components of the health care system that can be modified to support high-quality, patient-centered chronic disease management.1 The CCM provides a systematic approach to practice transformation. Interrelated elements of the CCM include:

  • Health systems, including culture, organizations, and mechanisms to promote safe, high-quality care
  • Decision support based on evidence and patients’ preferences and needs
  • Clinical information systems to organize patient and population data
  • Patient self-management support to enable patients to manage their health and health care
  • Community resources to mobilize patient resources
  • Delivery system design for clinical care and self-management support, including team care

The CCM has been used in a variety of health care settings to guide systematic and individual improvement in chronic illness care, including diabetes.2,3,4 Previous studies demonstrate the effectiveness of interventions for patients and diabetes-related outcomes based on specific components of the CCM.5,6,7

More information on the CCM can be found at Improving Chronic Illness Care: The Chronic Care Model. The Agency for Healthcare Research and Quality also offers a Toolkit for Implementing the Chronic Care Model in an Academic Environment.