Table 1

Components of the Chronic Care Model for health systems

Definition and examples of CCM components

Decision support

Embedding evidence-based guidelines into daily clinical practice (e.g., systems prompts and reminders; clinical pocket guides)

Delivery system design

Defining staff roles and distributing tasks appropriately among health team members to deliver coordinated care (e.g. use of non-physician staff to deliver counseling and coordinate care; clearly defined provider roles and responsibilities)

Clinical information systems

Utilizing patient and population data to facilitate efficient care, tracking and follow up (e.g., electronic medical records; patient registries; patient status summaries)

Patient self-management

Empowering patients to manage their own health through education and self-management support strategies (e.g., tailored educational resources; psychosocial support)

Cantrell and Shelley BMC Family Practice 2009 10:81   doi:10.1186/1471-2296-10-81

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