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Chronic Care Management

Although we know the essential elements of good care for people with chronic conditions, there is a gap between what we know and what we do. Providers are doing their best, but too often the systems in which they work make it difficult to provide good care. By changing systems, we are closing that gap. Hundreds of health care provider organizations have already shown impressive improvements in the health of those they serve.


Start here:

  • 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.
  • To assess your organization's current levels of care with respect to the six components of the Chronic Care Model, use the Assessment of Chronic Illness Care Survey.

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Getting Started: How to Improve

Learn about the Model for Improvement, forming the improvement team, setting aims, establishing measures, and selecting and testing changes. Go to How to Improve.