Diabetes and the chronic care model: a review.

There is a significant gap between evidence-based diabetes care and actual care delivery. The Chronic Care Model (CCM) was developed to bridge this gap and translate scientific knowledge directly to the care of patients. The CCM is a primary care based framework that identifies the essential elements of high quality chronic disease care. It includes attention to self-management support, delivery system design, decision support, information technology, community linkages, and the health care organization as a whole. This review will describe these elements and provide evidence for their use in improving diabetes care. Evidence for the CCM as a whole will also be presented.