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HOME ► Physician Office Quality ► Improving Clinical Care ► Chronic Disease Management ► Chronic Care Model: Key Information

Chronic Care Model: Key Information

Focus of the Chronic Care Model (CCM) is on improving the effectiveness of outpatient chronic illness care to achieve what is characterized as “productive interactions” and resulting in improved outcomes. The health care environment is presented as a system within the community environment and utilizing community resources. The health care system is characterized as an organization providing care that is impacted by elements of the practice related to:

Self-management support (for patients and/or their caregivers)

Patient plays a central role in managing health. Support strategies include assessment, goal-setting, action planning, problem-solving, and follow-up. Provide access to internal and community resources for support.

Delivery system design

Use planned interactions to provide evidence-based care. Complex patients require clinical case management services and regular follow-up by the care team. Patients’ cultural background must be considered in designing care.

Decision support

The use of evidence-based guidelines must be embedded into daily clinical practice. Share evidence-based guidelines with patients to encourage their participation (self-management). Integrate and coordinate specialist expertise and primary care.

Clinical information systems

It is important to monitor performance of the care team and of the system. Information, including data, needs to be shared to support care coordination. Providers and patients benefit from the use of timely reminders for care (be proactive).

Physician offices are challenged to create an organization that promotes safe, high-quality care and self-management support. Errors and quality problems are to be handled in an open and systematic way to improve care.

Physician offices are called to encourage patients to access effective community programs for support. Providers are also called to form partnerships with community organizations to support and develop interventions to fill gaps in services within the community.

No single intervention is sufficient to create and maintain the changes required to achieve improved outcomes. The most effective interventions include aspects that cross between multiple elements of the health care system identified above.


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