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Conceptualization of the Chronic Care Model

Implications for Home Care Case Manager Practice

Garland-Baird, Lisa, RN, MN; Fraser, Kimberly, PhD

doi: 10.1097/NHH.0000000000000699

One of the greatest challenges for healthcare systems is the management and prevention of chronic diseases. Wagner's Chronic Care Model aims to transform the daily care of patients with chronic illnesses from acute and reactive to proactive, planned, and population-based. The purpose of this article is to provide a review of the available research relating to the Chronic Care Model and consider the implications for Home Care Case Management practice. A total of 18 research studies (5 qualitative and 13 quantitative) were reviewed. A thematic content analysis approach was used. The findings included three themes: Chronic Care Model and positive chronic illness health behaviors and outcomes; Chronic Care Model and delivery of quality chronic illness care; and the importance of the supportive role of the home care nurse in the role of Home Care Case Management. Gaps and limitations of the Chronic Care Model in relation to Home Care Case Management were identified and discussed in relationship to partnership building and reciprocal trust between patients, family caregivers, and the Home Care Case Manager. Finally, implications for the use of the Chronic Care Model in Home Care Case Manager practice, policy development, and future research were presented.

Lisa Garland-Baird, RN, MN, is a Faculty of Nursing, University of Alberta, Edmonton, Alberta.

Kimberly Fraser, PhD, is an Associate Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta.

The authors declare no conflicts of interest.

Address for correspondence: Lisa Garland-Baird, RN, MN, 3040 Fort Augustus Road, Rt 21, Websters Corner, PEI, C1B2B5 (

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