U.S. Department of Health and Human Services

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.


1. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4.
2. Si D, Bailie R, Weeramanthri T. Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: A systematic review. Prim Health Care Res Dev. 2008;9:25-40.
3. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75-85.
4. Warm EJ. Diabetes and the chronic care model: A review. Curr Diabetes Rev. 2007;3(4):219-25.
5. Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811-7.
6. Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: A system-wide randomized trial. Diabetes Care. 2001;24:695-700.
7. Siminerio L, Zgibor J, Solano F. Implementing the chronic care model for improvements in diabetes practice and outcomes in primary care: The University of Pittsburgh Medical Center experience. Clin Diabetes. 2004;22:54-8.

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