Practice Facilitation Handbook

Module 16. Introduction to the Care Model

Table of Contents

Practice facilitation has frequently been used in disease-specific or other discrete quality improvement projects. Increasingly, facilitation is being used to effect a transformation of the primary care setting.

Currently the U.S. health care system is organized to deliver short-term medical treatment for an acute health condition, not to promote health and well-being or management of chronic health conditions. The Group Health Cooperative of Puget Sound, with funding from the Robert Wood Johnson Foundation, developed the Care Model (originally called the Chronic Care Model) as an alternative to the acute care-focused delivery system (Wagner, et al., 2001).

The Care Model

As shown in Figure 16.1, the Care Model depicts three overlapping spheres in which chronic care takes place: community, health systems, and provider organization (Bodenheimer, et al., 2002). The Care Model consists of five core elements: health systems, delivery system design, decision support, clinical information systems, and self-management support. These in turn produce productive interactions between informed, activated patients and prepared, proactive practice teams.

Figure 16.1. The Care Model

Diagram of Care Model, which includes Community and Health Systems. Community includes Resources and Policies. Health Systems involves organization of health care, including self-management support, delivery system design, decision support, and clinical information systems. Community leads to informed, activated patient, and health systems leads to prepared, proactive practice team. The two engage in productive interactions that lead to improved outcomes.

Developed by the MacColl Center for Health Care Innovation. ® ACP-ASIM Journals and Books. Used with permission.

The Care Model calls for an organized and planned approach to improving patient health. This approach focuses on particular patient populations (e.g., individuals with coronary artery disease) to ensure that every patient receives optimal medical care. It also encourages a shift from care delivered mainly by the physician to one that encourages care delivered through teams. Each team member brings unique and needed expertise to the table.

The Care Model has gained international recognition for identifying the essential elements of a health care system that encourages high-quality care. Numerous studies suggest that redesigning care using the Care Model leads to improved patient care and better health outcomes (Coleman, et al., 2009).

Patient-Centered Medical Home

The Care Model was formative in the development of the patient-centeredness movement. Over the past decade the patient-centered medical home (PCMH) has become a popular framework for transforming primary care. Briefly, the Agency for Healthcare Research and Quality has characterized the PCMH by five functions and attributes:

  • Comprehensive care.
  • Patient centeredness.
  • Coordinated care.
  • Accessible services.
  • Quality and safety.

To underscore the compatibility of the two approaches, the Care Model has been expanded to explicitly include elements of PCMH (see Figure 16.2).

Figure 16.2. Expanded Care Model

This expanded diagram of the Care Model adds Services as a component between community and patients and health systems and practice teams. Services are patient centered, timely and efficient, evidence based and safe, and coordinated. In addition, informed, activated patient is expanded to be informed, empowered patient and family.

Source: 1996-2011 The MacColl Center for Health Care Innovation. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health’s MacColl Center for Health Care Innovation. Used with permission.

Many organizations that seek to become a PCMH use the Care Model to operationalize the broad principles and the aspirational vision of the PCMH. Facilitators assisting practices striving to attain PCMH status can rely heavily on the tools that have been produced to aid in Care Model implementation.


Agency for Healthcare Research and Quality. Defining the PCMH. Patient Centered Medical Home Resource Center. Available at: Accessed April 30, 2012.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002 Oct 9;288(14):1775-9.

Coleman K, Austin B, Brach C, et al. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28(1):75-85. Available at: Accessed April 8, 2013.

Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001 Nov-Dec;20(6):64-78.

Page last reviewed May 2013
Page originally created May 2013
Internet Citation: Module 16. Introduction to the Care Model. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.
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