The Chronic Care Model (CCM) is a health care delivery system, developed by
Ed Wagner, MD, MPH, of Group Health Cooperative of Puget Sound, that encourages high-quality chronic disease management. The CCM is organized around elements that have been shown to improve chronic disease care and outcomes and provides a systematic approach for practice transformation. The premise of the CCM is that quality diabetes care is not delivered by clinicians in isolation and can be enhanced by practice systems that include links to community resources, self-management support, delivery system redesign, decision support, clinical information systems, and organizational support working synergistically to optimize patient-provider interactions.
The University of Pittsburgh Diabetes Institute has used the to implement and evaluate innovative approaches and strategies to improve diabetes care processes and outcomes in practice and community settings.