Community resources and policies	Provider organisations are linked to community-based resources, for example, exercise programmes, senior centres and self-help groups
Health care organization	Chronic care is seen as a priority with adequate reimbursement
Self-management Support	Patients themselves become the principal caregivers, taught to manage their illnesses, with lifestyle issues under the direct control of the patient. Self-management support involves collaboratively helping patients and their families acquire the skills and confidence to manage their chronic illness, providing self-management tools and routinely assessing problems and accomplishments
Delivery system design	Planned management of chronic conditions is separated from acute care. Non-physicians support patient self-management, arrange for routine periodic tasks and ensure appropriate follow-up
Decision support	Evidence-based clinical practice guidelines provide standards for optimal chronic care integrated into daily practice. Specialist expertise is available without full specialty referral. Guidelines are reinforced by educational sessions for practice teams
Clinical information systems	Registries, a central feature of the Chronic Care Model, are lists of all patients with a particular chronic condition in a healthcare organisation. Reminder systems help teams comply with practice guidelines. The system provides feedback showing how each professional is performing on chronic illness measures. Registries are used to plan both the individual patient care and the population-based care