Table 1. Elements of the Chronic Care Model [31].

Health system—Organization of healthcare	• Emphasizes the need for organizational goals to prioritize chronic care. • Requires strong leadership that exhibits traits such as creativity, compassion and advocacy, focuses on optimizing care delivery, and ensures patient-centeredness. • The set-up of the financial structure including remuneration and relationships with purchasers and insurers is integral to the CCM and must recognize and reward high quality chronic care.
Self-management support	• It is critical for people living with chronic conditions to receive support to manage their own care, and to be positioned as equal collaborators in their care.
Delivery system design	• Highlights the need for team-based care, with interdisciplinary team members having clear roles in proactively optimizing patient visits.
Decision support	• Ensures the integration of evidence-based guidelines into daily clinical practice. • Facilitates access to specialist expertise, specifically within primary care settings.
Clinical information systems	• Computerized systems can be used to implement decision support strategies, provide quality metrics back to physicians, and create clinical registries for management of patient populations.
Community resources and policies	• Linkages with community-based resources are necessary to enhance care for people with chronic conditions.