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The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.
The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings, and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
For citations concerning the evolution of the Chronic Care Model, please reference this journal article: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4. (The Chronic Care Model image first appeared in its current format in this article.)
The Care Coordination Model looks at care coordination from the perspective of a patient-centered medical home (PCMH). It considers the major external providers and organizations with which a PCMH must interact – medical specialists, community service agencies, and hospital and emergency facilities – and summarizes the elements that contribute to successful referrals and transitions.
The Care Coordination Model and accompanying toolkit are designed for clinics, practices, and health systems focused on improving care coordination by transforming the way they manage patient referrals and transitions.
Suggested citation: Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Kaiser Permanente’s MacColl Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011.
The MacColl Center encourages the
non-commercial use or adaptation of the materials we develop. With the exception of the Chronic Care Model image at left, all other materials provided here are publicly available, free of cost and copyright protected.
Please email us at email@example.com for help finding additional tools from Improving Chronic Illness Care.
The MacColl Center's funding for Improving Chronic Illness Care ended in 2011, but our work to improve care with a patient-centered, team-based approach has continued. To access some of our more recent tools and resources, please visit these websites:
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