Chronic Disease Management: the Chronic Care Model for Diabetes

Richard A. Kimball, Jr.
Richard A. Kimball, Jr.

In 2013, the Center for Disease Control and Prevention (CDCP) conducted a study on chronic disease management using the systematic review method. In particular, the study focused on the Chronic Care Model (CCM) as applied to diabetic patient care. The study aimed to describe how various researchers have applied CCM to provide care for people who live with diabetes. It also aimed to describe the outcomes of the model’s implementation.

Chronic Care Model (CCM)

CCM utilizes a systematic approach to restructure medical care so that partnerships and beneficial relationships are created between healthcare systems and communities. This kind of system is expected to facilitate improved quality of care and health outcomes for chronic disease patients.

CCM is comprised of 6 components: 1) health system or organization of healthcare (i.e., developing leadership for removing barriers to care); 2) self-management support (i.e., encouraging patient empowerment); 3) decision support (i.e., providing guidance for care); 4) delivery system design (i.e., coordinating care processes); 5) clinical information systems (i.e., reporting outcomes to patients and providers),; and 6) community resources and policies (i.e. working with public health policy to sustain care).

These components are hypothesized to positively affect outcomes associated with disease management.

CCM and diabetes

Diabetes is a major chronic disease in the United States with 29.1 million or 9.3% of the population suffering from the illness. It is also a major cause of heart disease and stroke among US adults, and is the leading cause of non-traumatic lower-extremity amputations and kidney failure.

Comprehensive models of care, such as CCM have been widely applied to cases of diabetes. The model calls for evidence-based healthcare system changes that can meet the growing need of people suffering from diabetes and other chronic diseases. CCM has been adapted in various settings such as schools and workplaces to provide diabetes patients with self-management skills and tracking systems.

Systematic review

The proponents of the CDCP study conducted an initial review of a total of 79 academic articles on CCM. Out of this, 16 were chosen for the final analysis. The rest were discarded for reasons such as being beyond the scope of the study’s focus, lack of details on how the CCM method was applied, and focus on other diseases aside from diabetes. The final roster of studies represented well-documented research that emphasized the interaction between CCM and diabetes care.


The CDCP study investigated the relationship between the applications of the 6 CCM components on diabetes care in the US. Through systematic, meta-analysis, it was found that interventions based on CCM have been generally effective for managing diabetes.

CCM was shown to facilitate better leadership and management of resources, consistent communication between patient and provider, and more patient-centered interactions, resulting in achieving more positive functional and clinical outcomes. This study supports the call for more evidenced-based, patient-centered models of care for managing chronic diseases.

7 Responses

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    Diabetes patients should be taught self-management skills and offered a tracking system to be able to effectively manage treatment and medication for the disease. As a chronic disease, diabetes requires attention and more communication between the patient and the medical provider.

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    As the obesity rate increases, there is little that is going to change the rate of diabetes from going up as well. It is sad and I often wonder if it comes down to education or genetics.

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    Exactly; diabetes management requires continuous tracking and a complete lifestyle change. As a lifestyle disease, it’s important to take diabetes seriously including interventions done at home.

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    I never heard of this Chronic Care Model (CCM) but as what I have read, it seems like a good idea. I hope this is the answer to all patients with chronic or terminal medical conditions.

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    This is one of the many diseases that must be managed. This article can be taken even further with this post:

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    I think what people don’t realize is that, even though we’ve been vaccinating for years, it takes that one child who doesn’t get their shots to turn a disease into a super disease, causing those who have been vaccinated to become susceptible to this new disease. Richard Kimball makes some excellent points here. I highly recommend following him on twitter.

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    Wow, I didn’t realize how common diabetes was. Thank you for sharing this information, Richard Kimball. I also enjoy reading your posts on your blog.

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