Chronic Care Model


  • Luigi Apuzzo Hospice Carlo Chenis, ASL ROMA 4, Civitavecchia (RM) - Italy
  • Maddalena Iodice UOC Ostetricia e Ginecologia, Ospedale San Paolo ASL ROMA 4, Civitavecchia (RM) - Italy
  • Margherita Gambella Facoltà di Medicina e Chirurgia, Università degli studi di Sassari, Sassari - Italy
  • Angelica Scarpa Facoltà di Medicina e Chirurgia, Università degli studi di Sassari, Sassari - Italy
  • Francesco Burrai SC Formazione, Ricerca e Cambiamento Organizzativo, ATS Sardegna, Sassari, ASSL di Sassari - Italy



Chronic Care Management, Chronic Care Model, Chronic diseases, Governance, Integrated care


In recent years, the incidence rate of chronic diseases shows a steady increase in every industrialized Country. The almost logarithmic trend of the number of people living with chronic diseases is constantly on the rise. Each predictive statistical model indicates a strong impact for national health systems at the level of the organization of care and management costs. It is urgent to systematically introduce an evidence-based care model in chronic care management such as the Chronic Care Model. The Chronic Care Model is the reference model for WHO. The Chronic Care Model allows for personalized, holistic, multi-professional assistance, characterized by a strong humanization of care, by preventive interventions and relationships between healthcare professionals, patients and caregivers as a system of care and assistance. The fundamental roles are social integration and the improvement of the quality of life of patients. The Chronic Care Model involves the use of a computerized system of information flow and telemedicine and trained healthcare professionals. The Chronic Care Model showed an improvement in the quality of life, a reduction in the number of hospitalizations, a better adherence to therapies, and a reduction in costs.


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How to Cite

Apuzzo, L., Iodice, M., Gambella, M., Scarpa, A., & Burrai, F. (2021). Chronic Care Model. Giornale Di Clinica Nefrologica E Dialisi, 33(1), 141–145.



Original articles


Received 2021-02-08
Accepted 2021-10-06
Published 2021-10-29


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