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Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:


Footnotes & Citations

Chronic Care Model citations:

  1. Bodenheimer T1, Chen E, Bennett HD. "Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job?" Health Aff (Millwood). 2009 Jan-Feb;28(1):64-74. doi: 10.1377/hlthaff.28.1.64.
  2. D.H. Stockwell, S. Madhavan, H. Cohen, G. Gibson and M.H. Alderman, "The determinants of hypertension awareness, treatment, and control in an insured population", American Journal of Public Health 84 (1994): 1768-1774.
  3. S.J. Kenny et al., "Survey of physician practice behaviors related to diabetes mellitus in the U.S.: Physician adherence to consensus recommendations", Diabetes Care 16 (1993): 1507-1510.
  4. J.M. Perrin, Homer CJ, Berwick DM, Woolf AD, Freeman JL, Wennberg JE. "Variations in rates of hospitalization of children in three urban communities", New England Journal of Medicine 320: 1183-1187.
  5. E.H. Wagner, B.T. Austin and M. Von Korff, "Improving outcomes in chronic illness", Managed Care Quarterly 4 (1996): (2) 12-25.
  6. E.H. Wagner, B.T. Austin and M. Von Korff, "Organizing care for patients with chronic illness", Milbank Quarterly 74 (1996): 511-544.
  7. E. Calkins, C. Boult, E.H. Wagner and J. Pacala, "New Ways to Care for Older People: Building Systems Based on Evidence", New York: Springer; (1999).
  8. D.K. McCulloch, M.J. Price, M. Hindmarsh and E.H. Wagner, "A population-based approach to diabetes management in a primary care setting: early results and lessons learned", Effective Clinical Practice (1998):12-22.
  9. M. Von Korff, J. Gruman, J.K. Schaefer, S.J. Curry and E.H. Wagner, "Collaborative management of chronic illness", Annals of Internal Medicine 127 (1997): 1097-1102.
  10. W. Katon, M. Von Korff, E. Lin, E. Walker, G.E. Simon, T. Bush, P. Robinson and J. Russo, "Collaborative management to achieve treatment guidelines", Journal of the American Medical Association 273 (1995): 1026-1031.
  11. M.R. Greenlick, "The emergence of population-based medicine", HMO Practice 9 (1995): 120-122.
  12. E.H. Wagner, "Population-based management of diabetes care," Patient Education and Counseling 16 (1995): 225-230.
  13. E.H. Wagner, C. Davis, J. Schaefer, M. Von Korff, B. Austin, "A survey of leading chronic disease management programs: are they consistent with the literature?", Managed Care Quarterly 7 (1999): (3) 56-66.
  14. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. "Impact of Recent Increase in Incidence on Future Diabetes Burden, U.S., 2005-2050". Diabetes Care, 2006, 29 (9), 2114-2116.
  15. Committee on Quality of Health Care in America,  Institute of Medicine, "Crossing The Quality Chasm:  A New Health System for the 21st Century", Washington DC : National Academy Press; (2001).
  16. Coleman K, Austin BT, Brach C, Wagner EH.  "Evidence on the Chronic Care Model in the new millennium".  Health Aff (Millwood). 2009 Jan-Feb;28(1):75-85.
  17. The Primary Care Team Guide was designed to show how to build care teams and redesign the work of patient care for primary care practices.  (