Comprehensive system changes, rather than simply implementing
sole interventions or adding new features to the existing
acute-focused system, are needed to provide effective and highquality
chronic care [9–13]. The chronic care model (CCM) guides
quality improvement in chronic care delivery by providing a
framework of how primary health care practices can change their
care delivery from acute and reactive care to chronic and proactive
care that is organized, structured, and planned, through a
combination of effective multidisciplinary teams and planned
interactions with chronically ill patients [1]. These steps, such as
providing self-management support, effective use of community
resources, integrated decision support for professionals, and the
use of patient registries and other supportive information
technology, are expected to result in a stronger provider–patient
relationship as well as improved health behavior