The Chronic Care Model

Nurse smiling with patient at home

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 management in primary care, specialty care, and inpatient settings.

Chronic care models are designed to optimize the care of patients who have or are at significant risk for chronic conditions. The MacColl Institute developed The Chronic Care Model in 1998, a model that has since gained traction across health care settings. This is the most widely implemented model for taking care of patients with chronic disease. Practices do not get “recognized” or “accredited” in this model; rather, it is about the processes and characteristics that demonstrate a practice with wrap around supports for patients with one or more chronic conditions.

The Chronic Care Model 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.

The Chronic Care Model aligns with principles of population health management, the PCMH model, and other patient-centered models of care.  In fact, many primary care practices that do see strategic value in seeking PCMH recognition choose instead to build their chronic care capacity based on the Chronic Care Model.

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2017-03-20T14:12:56+00:00August 12th, 2016|