ArticleBMC health services research2025
Key components of chronic care management programs: qualitative descriptions of care managers' practice.
Article in BMC health services research, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
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Who cites it
2 citing papers in PubMed.
- Healthcare Professionals' Perspectives on Nursing Competency: A Synthesis of Qualitative Evidence.International nursing review · 2026Review
- Developing, Implementing, and Evaluating a Care Management Model for Patients With Neuromuscular Diseases: Protocol for a Participatory Mixed Methods Study.JMIR research protocols · 2026Article
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Authors and funding
8 authors.
Funding
Abstract
backgroundIncreasing numbers of people live with chronic conditions. Yet, healthcare systems are often designed based on an acute care model that is not well-aligned with the needs of patients with chronic conditions, resulting in poor patient outcomes and high healthcare costs. To better assist patients living with chronic conditions, there is an urgent need to develop chronic care management models that are effective, scalable, and financially sustainable. The aim of this study was to identify and describe key components of chronic care management practice as a foundation to develop such a program.
methodsWe conducted a qualitative descriptive study interviewing care managers who care for patients living with chronic conditions in community settings. Eleven care managers were recruited from three healthcare organizations in the U.S. Pacific Northwest using a purposive sampling method. Individual interviews were conducted between July and December 2022 using a semi-structured interview guide developed by the researchers. Audio recordings of interviews were transcribed and analyzed using a thematic analysis approach.
resultsParticipants said that their practice was driven by the patient needs and tailored to their unique conditions and situations rather than to specific diagnoses. Five key components of chronic care management were: (1) whole person assessment; (2) patient-centered care planning; (3) direct care to assist patients to manage their needs; (4) care coordination; and (5) longitudinal evaluation and monitoring.
conclusionFindings from this study provide concrete descriptions of key components of chronic care management practice and contribute to filling gaps in the literature. Integration of these practice components in the design of chronic care management programs is a necessary next step to deliver effective chronic care. We discuss clinical and financial implications of these components, and recommend strategies and future steps to design pragmatic, effective, and financially sustainable chronic care management programs.
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