Strategic Plan: Vision Statement Comprehensive models of care, such as the original Chronic Care Model (CCM) (4,5), advocate for evidence-based health care system changes that meet the needs of growing numbers of people who have chronic disease. However, much of the literature is from the experience of high-income countries. Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. CCM was developed (4,5) to provide patients with self-management skills and tracking systems. How big of a problem is it? Six in ten Americans live with at least one chronic disease, like heart disease and stroke, cancer, or diabetes.These and other chronic diseases are the leading causes of death and disability in America, and they are also a leading driver of health care costs.. At CDC, our job is to make it easier for all Americans to make healthy choices so they can enjoy life. 5, 6, 7 To speed the transition, in 1998, Improving Chronic Illness Care created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels. And how do healthcare providers and teams manage chronic disease(s)? The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. There have been a number of frameworks created and reviewed over the years but we are going The document concludes that the Chronic Care Model should be implemented in its entirety since its components have synergistic effects, where the whole is greater than the sum of the parts. The size of the chronic disease population—–particularly patients with multiple comorbidities that require more health care resources—is projected to grow, reaching 157 million Americans by 2020. The chronic care model refers to a widely-used framework for organizing and providing care for people with chronic disease. Preventing Chronic Disease (PCD) is a peer-reviewed electronic journal established by the National Center for Chronic Disease Prevention and Health Promotion. Aim: To compare the effectiveness of multidisciplinary care with traditional medical care on the progression of chronic kidney disease (CKD) in adult pre-dialysis patients (stages 3-5). But what is chronic disease? A Review In a previously posted blog, the idea of health and chronic disease management was explored. Policy reforms and universal access to care are critical elements leading to better outcomes and reducing disparities in chronic disease care. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. Methods: Eleven databases were searched for articles published between January 1990 and July 2009. (ICIC, 2018) In this model, care is provided within a primary care setting, operating with a strategy of bringing together the patient, provider and system interventions necessary to accomplish the overall goal of improving care for chronic illness. Evidence on the effectiveness of the Chronic Care Model was summarized in 2009. Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). ensures evidence-based chronic disease self management programs to reach those affected by chronic disease, positively impacts quality of life, promotes access to care, and reduces health care costs. PCD provides an open exchange of information and knowledge among researchers, practitioners, policy makers, and others who strive to improve the health of the public through chronic disease prevention.