Thank you for visiting Improving Chronic Illness Care!

Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:


Steps for Improvement (1): Models

Learn About Improvement Models
There is a recipe for improving quality that involves evidence-based guidelines , system change strategies and quality improvement methods. You are all familiar with evidence-based guidelines, so let’s start with the system change strategy.

The Chronic Care Model
The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team.

The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems. Within each of these elements, there are specific concepts (“Change Concepts”) that teams use to direct their improvement efforts. Change concepts are the principles by which care redesign processes are guided.

The items below are the change concepts associated with each component of the model that, when implemented, result in improved patient and system outcomes.
Health Systems
Create an organization that provides safe, high quality care
A health system’s business plan reflects its commitment to apply the CCM across the organization. Clinician leaders are visible, dedicated members of the team.
  • Visibly support improvement at all levels of the organization, beginning with the senior leader
  • Promote effective improvement strategies aimed at comprehensive system change
  • Encourage open and systematic handling of errors and quality problems to improve care
  • Provide incentives based on quality of care
  • Develop agreements that facilitate care coordination within and across organizations
The Community
Mobilize community resources to meet needs of patients
Community resources, from school to government, non-profits and faith-based organization, bolster health systems’ efforts to keep chronically ill patients supported, involved and active.
  • Encourage patients to participate in effective community programs
  • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
  • Advocate for policies that improve patient care
Self-Management Support
Empower and prepare patients to manage their health care
Patients are encouraged to set goals, identify barriers and challenges, and monitor their own conditions. A variety of tools and resources provide patients with visual reminders to manage their health.
  • Emphasize the patient’s central role in managing his or her health
  • Use effective self-management support strategies that include assessment (physician or self?), goal-setting, action planning, problem-solving and follow-up
  • Organize internal and community resources to provide ongoing self-management support to patients
Delivery System Design
Assure effective, efficient care and self-management support
Regular, proactive planned visits which incorporate patient goals help individuals maintain optimal health, and allow health systems to better manage their resources. Visits often employ the skills of several team members.
  • Define roles and distribute tasks among team members
  • Use planned interactions to support evidence-based care
  • Provide clinical case management services for complex patients
  • Ensure regular follow-up by the care team
  • Give care that patients understand and that agrees with their cultural background
Decision Support
Promote care consistent with scientific data and patient preferences
Clinicians have convenient access to the latest evidence-based guidelines for care for each chronic condition. Continual educational outreach to clinicians reinforces utilization of these standards.
  • Embed evidence-based guidelines into daily clinical practice
  • Share evidence-based guidelines and information with patients to encourage their participation
  • Use proven provider education methods
  • Integrate specialist expertise and primary care
Clinical Information Systems
Organize data to facilitate efficient and effective care
Health systems harness technology to provide clinicians with an inclusive list (registry) of patients with a given chronic disease. A registry provides the information necessary to monitor patient health status and reduce complications.
  • Provide timely reminders for providers and patients
  • Identify relevant subpopulations for proactive care
  • Facilitate individual patient care planning
  • Share information with patients and providers to coordinate care
  • Monitor performance of practice team and care system
So What Does All This Mean?
Successful system change means you will redesign care within each of the six components of the CCM; it does not mean tweaking around the edges of an acute care system not capable of handling the needs of the chronically ill. You will be building a new system that works in concert with your acute care processes. You will accomplish this by testing the above change concepts and adapting them to your local environment. The remaining steps in this manual help focus where you can start making these changes.

Tools That Can Help
After learning more about the chronic care model, there are two things that may assist you in understanding how it directs system change. The first is the Assessment of Chronic Illness Care, which is a diagnostic survey that you and your team can complete together. The ACIC helps you identify that current state of your chronic care; what’s working and what is needed to achieve redesign in all components of the CCM.

The other tool is the ACT Report [PDF] (Shoeni, P. Accelerating Change Today: Curing the System, May 2002). This report provides concrete examples of teams that have redesigned their care based on the CCM. Some of the stories and the practices they represent may resonate with you and your team.

There Needs To Be a Quality Improvement Process
This is the final ingredient in the recipe. The Model for Improvement is a simple yet powerful tool for accelerating quality improvement changes in your organization. Developed by Associates in Process Improvement, the model has two parts. In the first part, your team will address three fundamental questions. These questions will guide your team in creating aims, measures, and specific change ideas. Secondly, your team will use Plan-Do-Study-Act (PDSA) cycles to allow these changes to be easily tested in your work environment.

Three Key Questions for Improvement
AIM:  What are we trying to accomplish?
When you answer this question, you are creating an aim statement – a statement of a specific, intended goal. A strong clear aim gives necessary direction to your improvement efforts. Your aim statement should include a general description of what your team hopes to accomplish, and a specific patient population on which your team will focus. A strong aim statement is specific, intentional, and unambiguous. It should be aligned with other organizational goals, and all those involved in the improvement process should support it.

MEASURES:  How will we know that a change is an improvement?
Your team will use a few simple measures to see if the rapid cycle changes in care are working. They can also be used to monitor performance over time. These measurements should not be confused with research. Where research focuses on one fixed and testable hypothesis, the methods for measuring improvement rely on sequential testing using practical measurement strategies. Keep in mind that the measures your team uses should be simple and directly aligned with your aim statement.
IDEAS:  What changes can we make that will result in an improvement?
Ideas for change to be tested come from evidence provided by previous research. These ideas are distilled into the design principles of the Chronic Care Model. They are used to develop testable ideas from your team’s own observations of the current system, stories from others, and creative thinking. When selecting specific ideas to test, consider whether an idea is directly linked to your stated aim, if it’s feasible, and if its implementation can provide good potential for learning.


PDSA Cycles
The PDSA (Plan-Do-Study-Act) cycle is a method for rapidly testing a change - by planning it, trying it, observing the results, and acting on what is learned. This is a scientific method used for action-oriented learning. After changes are thoroughly tested, PDSA cycles can be used to implement or spread change.
The key principle behind the PDSA cycle is to test on a small scale and test quickly. Traditional quality improvement has been anchored in laborious planning that attempts to account for all contingencies at the time of implementation; usually resulting in failed or partial implementation after months or even years of preparation. The PDSA philosophy is to design a small test with a limited impact that can be conducted quickly (days if not hours!) to work out unanticipated “bugs”. Repeated rapid small tests and the learnings gleaned build a process ready for implementation that is far more likely to succeed.

Parts of the PDSA Cycle
Plan:  In this phase, your objectives are defined and your team makes predictions about what will happen, and why it will happen. Your team will also prepare for the next step by answering the questions of who, what, where, and when.

Do:  In this phase, your team will carry out the plan and collect the data. This will include documenting experiences, problems, and surprises that occur during this test cycle.

Study:  In this phase, your team will analyze the test cycle and reflect on what you have learned. You will compare results with the predictions made in the planning stage, and draw conclusions based on the collected data.

Act:  In this last phase, your team will decide if there are any refinements or modifications needed to the change you have tried. This may lead to additional test cycles, which starts the process all over again with Plan.

After reviewing these materials, you are now ready to begin redesigning your system of care by implementing the change concepts in the Chronic Care Model. You will use the rapid cycle methodology of the Model for Improvement as the way to test small changes repeatedly until they are ready for implementation in your entire population of patients.