Although we know the essential elements of good care for people with chronic conditions, there is a gap between what we know and what we do. Providers are doing their best, but too often the systems in which they work make it difficult to provide good care.

By changing systems, we are closing that gap — and we can prove it. Hundreds of health care provider organizations have already shown impressive improvements in the health of those they serve.

To assess your organization's current levels of care with respect to the six components of the Chronic Care Model, use the Assessment of Chronic Illness Care Survey.

[Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]

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 who have the necessary resources and expertise.

Learn more about the changes that focus on the six components of the model and can be applied to a variety of chronic illnesses, health care settings, and target populations.