Chronic disease management programs

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Disparity Rating  
Disparity rating: Inconclusive impact on disparities

Strategies with this rating do not have enough evidence to assess potential impact on disparities.

Health Factors  
Decision Makers
Date last updated

Chronic disease management (CDM) programs are proactive, organized sets of interventions focused on the needs of a defined population of patients. Program design varies, but CDM programs are usually multi-component efforts that include planned visits to teach patients about their disease, coach them on healthy behavior change including medication adherence, and help develop skills for self-management of chronic conditions in partnership with a coordinated, multidisciplinary care team. Interventions may be based on the Chronic Care Model, which identifies links to community resources, health system support, health care system redesign, self-management and provider decision support, and the use of clinical information systems as essential elements for health care systems to support high quality chronic disease care. CDM programs can support patients with illnesses such as diabetes, hypertension, heart failure, and depression, and can be delivered in various health care settings1.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Improved quality of life

  • Improved health outcomes

  • Improved mental health

  • Reduced hospital utilization

What does the research say about effectiveness?

There is strong evidence that chronic disease management (CDM) programs improve quality of life2, 3, 4, 5, 6, 7 and health outcomes for a variety of chronic conditions2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, including mental illness3, 6, 11. CDM programs have also been shown to reduce hospital admissions or readmissions2, 3, 7.

CDM programs, and the Chronic Care Model specifically, have been shown to improve health outcomes in patients with diabetes10, 12, 13, 14, hypertension3, 9, 15, anxiety and depression3, 6, 11, COPD2, 16, and heart failure, including reducing mortality7. In some cases, such interventions also improve outcomes for patients with asthma4, osteoarthrosis17, and HIV18. Studies of CDM for patients with diabetes, asthma, and COPD indicate that using multiple components of the Chronic Care Model may increase program effectiveness8, 19.

CDM improves quality of life for patients3, including patients with asthma4, COPD2, 16, heart failure7, and anxiety and depression11. CDM may be more effective for patients with more severe mental illness than for those with less severe symptoms5.

Interprofessional collaboration opportunities for health care providers implementing CDM programs can improve health outcomes for patients with chronic diseases and may increase preventive behaviors, such as smoking cessation15. Disease management interventions for patients with multiple chronic diseases may improve some health outcomes but additional evidence is needed to confirm effects20, 21. Utilizing community health workers (CHWs) in CDM programs may improve primary care access and cancer screening22, 23, and can be cost effective, especially for vulnerable populations23.

Patient-centered medical homes (PCMH) appear more effective than standard primary care models in chronic disease management3. Some evidence suggests programs that combine physician decision-support interventions with patient self-management support interventions may lead to the largest improvement in patient outcomes24. However, further research is needed to evaluate which program components of disease management interventions and intervention duration is most effective for management of chronic diseases2.

How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.

It is unclear what impact chronic disease management (CDM) programs may have on disparities in chronic diseases.

People with one or more chronic diseases are at greater risk for disability, death, poor functional status, unnecessary hospitalizations, and many other challenges21. Individuals from minoritized racial backgrounds31, from rural areas32, and those with low incomes are disproportionately more likely to have one or more chronic disease33. Patients who are racial and ethnic minorities are almost twice as likely to be affected by major chronic diseases such asthma, diabetes, hypertension, obesity, and mental illness compared to patients who are white31. Similar disparities exist between patients with different incomes: for example, diabetes rates are twice as high among adults with lower incomes than those with higher incomes33. Rural residents, particularly those from minoritized backgrounds, are more likely to experience chronic diseases and have higher mortality rates than those in urban areas34. People living in disadvantaged areas (i.e., with lower levels of safety, walkability, access to health care, nutritious foods, recreation, and higher levels of stress) are at higher risk for negative health outcomes, including hypertension and diabetes, and these communities are disproportionately Black. Hypertension and diabetes are less likely to be adequately managed in Black patients, regardless of income level34.

What is the relevant historical background?

The Federal Housing Administration’s redlining practices entrenched racial residential segregation in the U.S. and resulted in fewer health care facilities, resources, and funding in urban areas with largely Black populations35, 36. Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods that are primarily Black and low income35. Formerly redlined neighborhoods are more likely to be near man-made environmental hazards producing pollution or toxins and have older homes in poor condition containing health hazards such as lead paint and mold37, and residents continue to experience worse health outcomes, including chronic diseases like diabetes36. Rural areas lack adequate access to physicians; approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there38.

Chronic diseases have increased in prevalence over the last century as public health and modern medicine became increasingly effective in preventing and treating communicable diseases and are now the leading causes of death. Unlike diseases caused by single pathogens, chronic diseases are often the result of multiple factors accumulating over time, with aspects of the neighborhoods and communities individuals live in harming them by restricting their opportunities for healthy living39. The chronic disease management (CDM) model emerged in the 1990s because of the increasing prevalence and complexity of treating patients with chronic illnesses40.

Equity Considerations
  • What are the disparities in chronic disease prevalence in your community? What groups are most affected?
  • What resources are available for chronic disease management? Are certain groups less able to access the care and services available?
  • What are the barriers to high quality linguistically and culturally appropriate chronic disease management services?
  • How can chronic disease management services be more equitably delivered? What partnership opportunities exist in your community to increase access to these services?
Implementation Examples

There are many types of CDM programs. The Upper Great Lakes Family Health Center in Michigan is an example of a health center collaborating with local agencies to coordinate behavioral healthcare in a primary care setting to address and treat substance use disorder and depression25. Middlesex Hospital in Middletown, Connecticut’s program is an example of a hospital-based outpatient effort that serves the sickest patients with asthma, heart failure, obesity, and diabetes26. The Sutter Care Coordination Program in the Sacramento Sierra region, which combines chronic care and disease management to address the medical and psychosocial needs of patients with multiple chronic conditions, is another example27.

As of January 2015, Medicare covers non-face-to-face chronic care management for patients with multiple chronic conditions who are at significant risk of death, acute exacerbation/decomposition, or functional decline28. The Centers for Medicare and Medicaid Services (CMS) Connected Care Toolkit can assist in the implementation of chronic care management programs29, and the National Center for Chronic Disease Prevention and Health Promotion within the Centers for Disease Control offers resources to advance equity in chronic disease prevention and management30.

Implementation Resources

Resources with a focus on equity.

CDC-Health Equity CCM - Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).

US DHHS-Connected Care Toolkit - U.S. Department of Health and Human Services (U.S. DHHS). Chronic Care Management Toolkit: Chronic care management resources for health care professionals and communities.

Nordian-CCM - Nordian Healthcare Solutions. Chronic Care Management.

RHIhub-CCM - Rural Health Information Hub (RHIhub). Chronic Care Management.

Fromer 2011 - Fromer L. Implementing chronic care for COPD: Planned visits, care coordination, and patient empowerment for improved outcomes. International Journal of COPD. 2011;6:605–614.


* Journal subscription may be required for access.

1 CCM - Improving chronic illness care. The Chronic Care Model (CCM): Model elements.

2 Cochrane-Poot 2021 - Poot CC, Meijer E, Kruis AL, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2021;(9):CD009437.

3 John 2020 - John JR, Jani H, Peters K, Agho K, Tannous WK. The effectiveness of patient-centred medical home-based models of care versus standard primary care in chronic disease management: A systematic review and meta-analysis of randomised and non-randomised controlled trials. International Journal of Environmental Research and Public Health. 2020;17(18):6886.

4 Cochrane-Peytremann-Bridevaux 2015 - Peytremann-Bridevaux I, Arditi C, Gex G, Bridevaux PO, Burnand B. Chronic disease management programmes for adults with asthma (Review). Cochrane Database of Systematic Reviews. 2015;(5):CD007988.

5 Miller 2013b - Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions: Cumulative meta-analysis and meta-regression to guide future research and implementation. Medical Care. 2013;51(10):922–930.

6 Cochrane-Archer 2012 - Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems (Review). Cochrane Database of Systematic Reviews. 2012;(10):CD006525.

7 Drewes 2012 - Drewes HW, Steuten LMG, Lemmens LC, et al. The effectiveness of chronic care management for heart failure: Meta-regression analyses to explain the heterogeneity in outcomes. Health Services Research. 2012;47(5):1926–1959.

8 Baptista 2016 - Baptista DR, Wiens A, Pontarolo R, et al. The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome. 2016;8(1):1-7.

9 CG-CVD 2015 - The Guide to Community Preventive Services (The Community Guide). Heart disease and stroke prevention: Cardiovascular disease (CVD).

10 Stellefson 2013b - Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in U.S. primary care settings: A systematic review. Preventing Chronic Disease. 2013;10:120180.

11 Woltmann 2012 - Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry. 2012;169(8):790–804.

12 Pimouguet 2011 - Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C. Effectiveness of disease-management programs for improving diabetes care: A meta-analysis. Canadian Medical Association Journal. 2011;183(2):E115–E127.

13 Si 2008 - Si D, Bailie R, Weeramanthri T. Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: A systematic review. Primary Health Care Research & Development. 2008;9(01):25–40.

14 CG-Diabetes - The Guide to Community Preventive Services (The Community Guide). Diabetes.

15 Pascucci 2021 - Pascucci D, Sassano M, Nurchis MC, et al. Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis. Health Policy. 2021;125(2):191-202.

16 Peytremann-Bridevaux 2008 - Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: Systematic review and meta-analysis. The American Journal of Medicine. 2008;121(5):433–443.e4.

17 Brand 2014 - Brand CA, Ackerman IN, Tropea J. Chronic disease management: Improving care for people with osteoarthritis. Best Practice & Research Clinical Rheumatology. 2014;28(1):119-142.

18 Pasricha 2013 - Pasricha A, Deinstadt RTM, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: A systematic review. Journal of General Internal Medicine. 2013;28(1):127–135.

19 Lemmens 2009 - Lemmens KMM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-management interventions in asthma and COPD. Respiratory Medicine. 2009;103(5):670–691.

20 Cochrane-Smith 2016 - Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (Review). Cochrane Database of Systematic Reviews. 2016;(3):CD006560.

21 Bleich 2015 - Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Preventing Chronic Disease. 2015;12:150275.

22 Mistry 2021 - Mistry SK, Harris E, Harris M. Community health workers as healthcare navigators in primary care chronic disease management: A systematic review. Journal of General Internal Medicine. 2021;36:2755-2771.

23 Kim 2016 - Kim K, Choi JS, Choi E, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: A systematic review. American Journal of Public Health. 2016;106(4):e3-e28.

24 Reynolds 2018a - Reynolds R, Dennis S, Hasan I, et al. A systematic review of chronic disease management interventions in primary care. BMC Family Practice. 2018;19:11.

25 RHIhub-Cross Walk - Rural Health Information Hub (RHIhub). Cross-Walk: Integrating Behavioral Health and Primary Care.

26 Middlesex Health-CCM - Middlesex Health. Chronic Care Management.

27 Sutter Care Coordination Program - Sutter Health. Sutter Care Coordination.

28 CMS-CCMS - Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network (MLN). Chronic care management services (CCMS). U.S. Department of Health and Human Services (U.S. DHHS); 2015.

29 US DHHS-Connected Care Toolkit - U.S. Department of Health and Human Services (U.S. DHHS). Chronic Care Management Toolkit: Chronic care management resources for health care professionals and communities.

30 CDC-Health Equity CCM - Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).

31 Price 2013 - Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States. BioMed Research International. 2013:787616.

32 RHIhub-Chronic Disease - Rural Health Information Hub (RHIhub). Chronic disease in rural America.

33 Eyler 2019 - Eyler AA, Valko CA, Marti M, et al. Adjusting the equity lens: Gaps in addressing health equity in state chronic disease prevention. Health Equity. 2019;3(1):86-91.

34 Durfey 2019 - Durfey SNM, Kind AJH, Buckingham WR, DuGoff EH, Trivedi AN. Neighborhood disadvantage and chronic disease management. Health Services Research. 2019;54:206-216.

35 Lee 2023 - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.

36 Lee 2022c - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.

37 Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.

38 Arredondo 2023 - Arredondo K, Touchett HN, Khan S, Vincenti M, Watts BV. Current programs and incentives to overcome rural physician shortages in the United States: A narrative review. Journal of General Internal Medicine. 2023;38:916-922.

39 Hong 2019b - Hong Y-C. Chapter 2: The age of chronic and late chronic diseases: A new view of diseases. In: The Changing Era of Diseases. Cambridge: Academic Press; 2019:35-68.

40 Wagner 1998 - Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.