The Chronic Care Model: What is It?
The chronic care model (CCM) uses a standardized path to restructuring medical care in
a way that builds partnerships between heath systems and communities. The CCM is
based on the idea that improvement in care necessitates an approach that incorporates
patient, provider, and system-level intervention. CCM has been applied to many chronic
conditions including diabetes, congestive heart failure, and asthma. A chronic condition
is any that requires ongoing adjustment by the affected person and interactions with
the health-care system. Almost half of people have at least one chronic condition.
Successful mediations in the care of chronic disease include intricate sets of actions that
address psychosocial and lifestyle issues, in addition to physical problems. The CCM
model is developed on the belief that improvements in care require an approach that
considers patient, provider, and system-level interventions.
In any health-care setting, best management of chronic disease and practice
improvement must be a priority. Other recommendations for ideal practice include:
leadership that is committed and visibly involved; leadership that backs innovation and
quality improvement; leadership that develops incentives for providers and patients for
better care and to stick to evidence-based practices. Practice leaders must make their
expectations clear at all times and provide adequate resources to support chronic care
and practice improvement programs. Obviously, practice improvement requires the
review of data and trends in individual patients and the practice population. Clinical
information systems are organized to include patient, population, and provider data to
portray the health of the population and to aid efficient and effective care. The system
should include a disease registry that provides information on the population and
provider performance of guidelines. In the CCM, this registry might also include a
registry regarding patient-specific needs and reminder systems that might generate
tailored treatment planning or encounter forms, or provide tailored patient or provider
messaging. Delivery system design should allow for appropriate use of all team
members, planned patient visits, regular follow-up, and case management.
There are seven components of CCM believed to affect functional and clinical outcomes
associated with disease management. They are:
1. Health system – organization of health care (ie, providing leadership for securing
resources and removing barriers to care)
2. Self-management support – ie, facilitating skills-based learning and patient
empowerment. Instead of solving a problem for a patient, the practitioner
should teach the patient how to solve problems for themselves.
3. Decision support –ie, providing guidance for implementing evidence-based care.
Tools for decision making are often based on information and can include skills
such as how to read a food label.
4. Delivery system design – ie, coordinating care processes
5. Clinical information systems – ie, tracking progress through reporting outcomes
to patients and providers
6. Community resources and policies – ie, sustaining care by using communitybased resources and public health policies. Coaching the patient to learn to
identify, evaluate, and use available resources is an important part of selfmanagement support. Community practice partnerships are especially important
with elders, low-income, and underserved individuals.
7. Taking action – this involves readiness to change, sufficient information, goal
setting, and ongoing support for change
Deficiencies in current care include:
 Rushed practices not following established practice guidelines
 Lack of care coordination
 Lack of active follow-up to ensure best outcomes
 Patients inadequately trained to manage their illnesses
The Robert Wood Johnson Foundation mandated rigorous independent evaluation of
the collaborative improvement process and the implementation of the CCM by health
systems. In 1999, the RAND corporation and the University of California at Berkeley, in
cooperation with the Improving Chronic Illness Care, a national program of The Robert
Wood Johnson Foundation, undertook a four-year study of Improving Chronic Illness
Care’s three earliest chronic illness care collaboratives, involving 51 participating sites
involving almost 4 000 patients with diabetes, congestive heart failure (CHF), asthma,
and depression. More than 15 papers were published based on these assessments
detailing:
 Organizations were able to improve, making an average of 48 changes in 5.8 out
of 6 CCM areas.
 Among people with diabetes, cardiovascular risk was significantly reduced.
 CHF pilot patients were more knowledgeable and more often on recommended
treatment with 35% fewer hospital days.
 Asthma and diabetes pilot patients were more likely to receive appropriate
therapy.
 A year later, care teams reported that 82% of sites had sustained changes and
79% of sites had spread changes to other places or diseases.
The example of CCM for diabetes management
The Centers for Disease Control (CDC) looked at 16 studies to discern how researchers in
the United States have practiced CCM in primary care settings in order to provide
improved care for individuals with diabetes and to describe the outcomes of the CCM
application. CCM was found to be effective and the following examples of initiation
were provided:
 The original leaders in health-care systems instituted system-level reorganization
that improved coordination of care.

Disease registries and electronic medical records (EMRs) were used to create
patient-centered goals, monitor patient development, and identify negligence in
care.
 Primary care physicians (PCPs) were trained to deliver evidence-based care.
 PCP office-based diabetes self-management education improved patient
outcomes.
Specific outcomes of CCM application included:
 Engaging the governing boards of health-care systems culminated in support for
institutionalizing the CCM approach, which was associated with a 1% drop in A1c
over a year, as well as improved foot care.
 Two studies revised the health-care system to reformulate health-care team
roles, resulting in improved A1c, blood pressure, cholesterol, and weight.
 Health-care system reorganization helped to build diabetes self-management
training programs that identified and intervened with patients at risk for
complications; this improved both clinical and behavioral outcomes.
 Diabetes self-management education generally improved psychosocial and
clinical outcomes.
 Weekly automated, individualized, phone calls from registered nurses (RNs) are
linked to improvement in interpersonal processes of care, physical activity and
function, and slightly better metabolic outcomes (ie, A1c, blood pressure, and
cholesterol).
 Use of secure email connection and smartphone apps to upload glucose readings
allowed patients to feel more allied with their RN care manager (note that some
patients still preferred face-to-face interaction).
 Computer-based interactive diabetes self-management training modules and
toolkits were supported by a “DM passport” or “DM care record” that listed
goals, action plans, and labs.
 Training PCPs on evidence-based guidelines and methods for implementing CCM
culminated in improved PCP adherence to clinical guidelines. Training the PCPs
led to improved diabetes knowledge among patients and improved A1c and high
density lipoprotein (HDL) results.
 Implementation of the American Diabetes Association’s (ADA’s) Standards of
Care and Institute for Clinical Systems Improvement clinical guides increased the
number of planned visits solely for diabetes and resulted in improved
communication between certified diabetes educators (CDEs), PCPs, and patients.
A1cs were improved, patients reported better constancy in medication regimens
and adjustment practices, and had stronger support networks in more
personalized settings. When diabetes self-management education was provided
in PCP offices instead of exclusively in hospitals, two- to three-fold more patients
were reached.
 Collective clinical information systems utilizing disease registries and EMRs
allowed multiple providers to review detailed lab and exam results and helped to
identify care lapses.
References and recommended reading
Fiandt K. The chronic care model: description and application for practice.
http://www.medscape.com/viewarticle/549040. Accessed December 3, 2015.
Improving chronic illness care. Improving Chronic Illness Care website.
http://www.improvingchroniccare.org. Accessed December 3, 2015.
Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management
in US primary care settings: a systematic review. Centers for Disease Control and
Prevention website. Prev Chronic Dis 2013;10:120-180.
doi:http://dx.doi.org/10.5888/pcd10.120180.
The chronic care model. Pittsburgh Regional Health Initiative website.
http://www.prhi.org/initiatives/readmissions-reduction/ed-wagners-chronic-caremodel. Accessed December 3, 2015.
Contributed by Elaine Hinzey RDN, LD/N
Review date: 12/2/15