Development of the Chronic Care Model

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The MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute developed the Chronic Care Model (CCM) in the mid-1990s by drawing on available literature about promising strategies for chronic illness management and organizing that literature in a new more accessible way.

The CCM was further refined in 1997 during a nine-month planning project supported by The Robert Wood Johnson Foundation (RWJF), and revised based on input from a large panel of national experts. It was then used to collect data and analyze innovative programs recommended by experts. RWJF funded the MacColl Center in 1998 to test the Model nationally across varied health care settings, creating the national program, "Improving Chronic Illness Care."

Chronic Care Model: Refinements

In 2003, the Improving Chronic Illness Care Program and a small group of experts updated the CCM to reflect advances in the field of chronic care both from the research literature and from the scores of health care systems that implemented the Model in their improvement efforts. We list more specific concepts under each of the six elements. Based on more recent evidence, five additional themes were incorporated into the CCM:

  • Patient Safety (in Health System)
  • Cultural competency (in Delivery System Design)
  • Care coordination (in Health System and Clinical Information Systems)
  • Community policies (in Community Resources and Policies)
  • Case management (in Delivery System Design)

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.)


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