The Chronic Care Model

Chronic care models are designed to optimize the care of patients who have or are at significant risk for chronic conditions.  The prevalence of chronic conditions has been increasing due to the aging of the population and rising levels of lifestyle-related risk factors.   Projecting these trends forward, the growing burden of disease and costs could be crippling.  Consequently, chronic care improvement is a high priority for population health improvement.

The Chronic Care Model as developed by the MacColl Institute is designed to optimize the capabilities and interactions between six key elements, including:

  • Health System Organization
  • Delivery System Design
  • Decision Support
  • Clinical Information Systems
  • Self Management Supports
  • Community Policies and Resources.

Implications for Practice

The Chronic Care Model aligns with principles of population health improvement, the PCMH model, and other patient-centered models of care.  In fact, many primary care practices that do not see strategic value in seeking PCMH recognition choose instead to build their chronic care capacity based on the Chronic Care Model.

Visit the The Improving Chronic Illness Care website for tools and resources to inform your work to improve chronic illness care for optimize care delivery for patients living with chronic illnesses.

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