The Chronic Care Model
The premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost, and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care, and we should work to change that, and they may be totally unaware of how we keep information to provide that care.
Wagner, E. H., Davies, C., Schaefer, J., Von Korff, M., & Austin, B. (1999). A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly, 7(3), 56-66.