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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:


Model Elements

The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.
The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
Development of the Chronic Care Model
The staff at the MacColl Center for Health Care Innovation at Group Health Research Institute developed the CCM in the mid-1990s by drawing on available literature about promising strategies for chronic illness management, and organizing that literature in a new more accessible way. The Model was further refined in 1997 during a nine-month planning project supported by The Robert Wood Johnson Foundation, and revised based on input from a large panel of national experts. It was then used to collect data and analyze innovative programs recommended by experts. RWJF funded the MacColl Center in 1998 to test the Model nationally across varied health care settings, creating the national program, "Improving Chronic Illness Care".
Refinements to the Chronic Care Model
In 2003, ICIC and a small group of experts updated the CCM to reflect advances in the field of chronic care both from the research literature and from the scores of health care systems that implemented the Model in their improvement efforts. We list more specific concepts under each of the six elements. Based on more recent evidence, five additional themes were incorporated into the CCM:
  • Patient Safety (in Health System);
  • Cultural competency (in Delivery System Design);
  • Care coordination (in Health System and Clinical Information Systems)
  • Community policies (in Community Resources and Policies); and
  • Case management (in Delivery System Design).
The Model element pages describe the overall strategy for each element, and the health system change concepts necessary to achieve improvement in that component. The 2003 refinements have been identified in the related Model Elements page for reference.