American Academy of Family Physicians

Printer-friendly version

Share this on AAFP Connection

Share this page

Chronic Care Model

The Chronic Care Model, developed by MacColl Institute for Healthcare Innovation, advocates for more productive interactions between the patient and his/her care team. It describes how the model elements work together to create a patient-centered, proactive health care team.

The model elements are:
  • Clinical information systems
  • Decision support
  • Delivery system design
  • Self-management support
  • Community and organizational leadership
Improving Chronic Illness Care: Overview of the Chronic Care Model -- Explore the elements of the Chronic Care Model.
CCM Presentation -- This online presentation walks you through the Chronic Care Model step-by-step with narration by model developer, Dr. Ed Wagner, national program director, Improving Chronic Illness Care.
Assessment of Chronic Illness Care -- This practice assessment tool will help you gauge how your practice is performing on the six dimensions of the Chronic Care Model.
Implement a QI Project

Chronic Care Model

Shop Catalog