Table 3. The Chronic Care Model: Components and Interventions.

Components of Chronic Care	Interventions
Delivery system redesign	Organize patient care teams that include the physician, nurses, and nonmedical staff Train nonphysician staff to provide routine assessment, prevention tasks, and self-management support Allocate tasks Have ready access to specialist care (eg, medical specialists, nutritionists, social workers) Use specialist care support as needed Assure regular patient contact through practice-initiated appointments and follow-up
Physician assisted patient self-management	Assess patient knowledge Provide patient education Mutually agree on the definition of the problem Set realistic goals to target issues of greatest importance to the physician and patient Develop a personalized intervention plan with patient input Provide self-management support tools (eg, disease management instructions, behavioral support programs, exercise options) Arrange for practice-initiated follow-up at regular intervals
Decision support	Conventional referral or consultation Increase expertise through continuing medical education Access to recent textbooks and journals Use of electronic evidence-based medicine resources Use of PDA-based prescribing resource Use of treatment algorithms Use of measurement-based care Use of electronic decision support systems with audits and reminders
Clinical information systems	Use computerized patient registries to facilitate reminders for follow-up and preventive care Provide patient-carried medical records and care plans Use an information system to get patient feedback Ensure access to longitudinal computerized patient information