Steurer-Stey C, Rosemann T
Institut für Hausarztmedizin, Universität Zürich, Universitätsspital Zürich und mediX Gruppenpraxis, Zürich.
Praxis (Bern 1994). 2010 May 26;99(11):655-9. doi: 10.1024/1661-8157/a000123.
The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems.
慢性病护理模式（CCM）是一种在初级护理环境中照顾慢性病患者的组织方法。该系统在知识渊博、积极主动的患者与有准备、积极主动的医疗团队之间建立实际、支持性且基于证据的互动。慢性病护理模式确定了鼓励高质量慢性病护理的医疗系统的基本要素：社区；卫生系统；自我管理支持；服务提供系统设计；决策支持以及临床信息系统。
