The Chronic Care Model

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The Chronic Care Model (CCM) is

  • a framework for producing healthy communities;
  • a multi-dimensional solution to a complex problem;
  • like an evidence-based guideline—a synthesis of system changes to guide quality improvement;
  • intended to be flexible and subject to change when new evidence emerges.

There are six major components in the Chronic Care Model:

  1. The Community: public and private resources and policies;
  2. The Health System: how health care is organized, including its payment structures;
  3. Self-Management Support: education, tools, motivational techniques, patient empowerment
  4. Delivery System Design: the structure of the provider organization (hospital system, clinic, doctor’s office) and the organization of patient encounters;
  5. Decision Support: clinicians can access and adhere to evidence-based guidelines for care;
  6. Clinical Information Systems: computerized information, medical records, decision support tools, reminders, etc.

There are thousands of examples around the U.S. of places that have successfully instituted pieces of this model, but no region has yet succeeded in putting all the components together.

There is no one way to implement the components of this model. For example, there are several successful designs for effective Clinical Information Systems or Self-Management Support techniques. The CCM is a guide, not a cookbook.


Dr. Ed Wagner
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Dr. Ed Wagner's "Chronic Care Model"
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