Chronic Care Model

The Chronic Care Model (CCM) emphasizes the fact that improved functional and clinical outcomes are the direct product of an informed, activated patient
, and a prepared, proactive practice team. The CCM’s primary practice-based components include: encouraging patients to engage in the management of their own healthcare and providing them with the resources and skills to obtain appropriate healthcare services; designing a delivery system to assure the provision of effective, efficient clinical care services; embedding clinical decision support tools into daily practice; and using information technology to support patient education, care planning and coordination, and the monitoring of performance. The system level attributes of the CCM that create a culture of safe and high-quality healthcare include the use of community resources, partnerships, and policies that support and organize the healthcare system. These elements of the CCM are vital to a healthcare delivery system that supports the economic viability of a practice’s structure.