Box 1. The seven steps of the chronic conditions model care (ACCM) and their main macroprocesses.

Steps	Main macroprocesses
1. Evaluation of the existing infrastructure and definition of improvements needed considering the reference population	Territorialization, registry of families, family risk classification, risk stratification of chronic conditions.
2. Primary care to acute health events	Patients’ reception at Health Unit, Manchester triage system, delivery of primary care according to Manchester protocol.
3. Primary care to patients with controlled chronic conditions	Management and monitoring of chronic conditions, risk stratification of chronic conditions, elaboration of patients care plan, self-care support.
4. Preventive care and tools to support behavior change	Physical activities, control of alcohol, tobacco and drugs, and nutritional re-education groups, motivational interviewing.
5. Administrative demands	Control of medical certificates, renewal of prescription of drugs and medicines, management of Health Units including information system, medical records and public health surveillance.
6. Home healthcare	Management and monitoring of household visits.
7. Self-care support	Self-care training and advice, elaboration of patients care plan, material support to self-care.

Source: Mendes ¹⁷ .