Chronic Care Model
There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers backed up by resources and expertise.
The changes described here can be applied to a variety of chronic illnesses, health care settings, and target populations.
[Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;11:2-4.]