Abstract
Although effective treatment of and care for some chronic diseases exist nowadays, the majority of
patients with such diseases still do not receive appropriate treatment. This is due to: (a) the rapidly rising
number of patients in parallel with the increasing age structure of the population, which exceeds the
ability of the existing health-care system; (b) the health-care system falling short in its ability to translate
knowledge into routine medical practice; and (c) the health-care delivery system being designed for acute
patient care; it is poorly organized for providing the full complement of services needed by people with
common chronic conditions. The chronic care model (CCM) was developed in the 1990s, based on the
premise that effective chronic illness care can be delivered by prepared provider teams who engage productively
with an activated, informed patient. The six dimensions of CCM that enhance this productive
interaction include the following: (1) self-management support; (2) delivery system redesign; (3) a clinical
information system; (4) decision support; (5) health-care organization; and (6) community policies and
resources. To date, CCM has been applied for patients with diabetes, cardiovascular disease, chronic
respiratory diseases and asthma, depression and HIV infection. Evaluation results, particularly for diabetes,
show that the implementation of CCM improves the process and immediate outcomes of care. However,
its long-term impact on patients’ longevity is still undetermined.
