There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers backed up by resources and expertise.
The changes described here can be applied to a variety of chronic illnesses, health care settings, and target populations.
[Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]
*The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues of the Improving Chronic Illness Care program with support from The Robert Wood Johnson Foundation.
The Chronic Care Model has also been found to be useful in a wide range of settings for different populations. For more information, see Chronic Care Model: Changes for Specific Populations
For more information and general tips on selecting changes, see Improvement Methods.
