[Chronic care model: an evidence-based approach to caring for people with chronic disease]

The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems.