TABLE 1.

Core Components of Wagner’s Chronic Care Model^a

Component	Focus	Example
Support of patient self-management	Allowing patients to recognize and manage their own symptoms, increase their sense of control, and participate more actively in their clinical care	Use of care managers to implement education programs, problem solving, and goal setting
Use of clinical information systems	Facilitation of the flow of information to improve patient care	Use of patient registries, pharmacy refill monitoring to assess medication adherence, shared electronic medical records for medical and behavioral health care
Delivery system redesign	Redefinition of roles for physicians and staff to promote preventative care, and creation of new positions as needed to support care model	Use of case managers and health educators, designated staff to monitor registries, increased screening
Decision-making support	Provision of expert-level input without need for real-time specialty consultation	Use of algorithms and practice guidelines, facilitated consultation with specialist as needed
Linkage to community resources	Support for nonclinical needs	Housing resources, peer support groups
Support from the health care organization	Leadership and resources to support practices	Provision of key staff and services, commitment to sustainability

^aSources: Wagner et al. (21), Woltmann et al. (24), and Gerrity et al. (25)