Table 2.

Elements of Chronic Care Model (CCM) included in each program

CCM component	P1	P2	P3	P4	P5	P6	P7
Health system
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	√	√		√	√	√	√
Delivery system design
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 fits with their cultural background				√	√	√	√
Decision support
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
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	√	√		√		√	√
Self-management support
Emphasize the patient’s central role in managing their health	√	√	√	√	√	√	√
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up	√	√	√	√	√	√	√
Organize internal and community resources to provide ongoing self-management support to patients	√	√	√	√		√	√
The community
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 to improve patient care	√				√		√