The Chronic Care Model identifies six fundamental areas that form 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 who have the necessary resources and expertise.
The changes listed below for each area of the Chronic Care Model can be applied to a variety of chronic illnesses, health care settings, and target populations.
Changes for Improvement
Developed by The MacColl Institute, © ACP-ASIM Journals and Books, reprinted with permission from ACP-ASIM Journals and Books.
Source: 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.