Chronic Care Model

The Chronic Care Model is a method of caring for people with chronic disease in the primary care setting. It encourages practical, supportive and evidenced-based chronic disease management using a proactive, rather than responsive approach. This approach creates patients who take an active part in their care. Using the Chronic Care Model has led to improved patient care and better outcomes for patients with chronic illness.

Six Components to the Chronic Care Model

Health System

This component addresses the culture, leadership and practices of the organization which encourages optimal management of chronic disease.

Delivery System 

The delivery system is designed to provide for efficient clinical care and self management support. This is done by focusing on keeping patients healthy and out of crisis. One way of doing this is by providing follow up after the patient leaves the doctors office. For more complex patients case management is provided.

Self Management Support

This component focuses on empowering the patient to manage their health care. Providers and patients use a collaborative approach to identify problems, set priorities, create goals and treatment plans, and solve problems that develop.

Decision Support

Treatment is determined by evidence-based guidelines which are discussed with the patient so that they become a participant in the decision making process. Providers need to be up to date on the latest evidences and involve specialists when appropriate.

Clinical Information Systems

This component focuses on the organization of patient data to ensure efficient and successful management of chronic disease.

Community Resources

Resources available in the community for care, peer support and education expand on the health systems treatment of chronic illness.