Table 1.

Chronic Care Model (CCM) Core Elements

Core Element	Focus
Healthcare Delivery System Redesign	Plan and manage to facilitate preventive care; redefine roles for the clinical team to implement CCM elements.
Healthcare Organization Support	Organization-level leadership and resources for CCM (e.g., organization leadership to sustain CCM).
Expert-Informed Decision Support	Provision of expert input to generalist clinicians to help manage cases without need for separate specialty treatment.
Improving Clinical Information Systems	Track and coordinate care, facilitate information flow among clinical sources, the clinical team and patients.
Fostering Patient Self- management	Coaching & problem solving to help patients self-manage disease and to participate in clinical decision making
Linking Patients to Community	Enhance access to community resources (e.g., peer support groups, exercise programs, housing, home care programs).

Source: Adapted from Bodenheimer, Wagner & Grumbach. Improving primary care for patients with chronic illness: the chronic care model, part 2. 2002.¹⁸