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Facilitators and barriers of implementing the chronic care model in primary care: a systematic review



The Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation.


This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Article abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies published after 2003 that described or evaluated the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study was adults over the age of 18 with chronic conditions. Studies were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis of cited barriers and facilitators using the Consolidating Framework for Research Implementation.


This review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs.


These findings highlight the importance of assessing organizational capacity and needs prior to and during the implementation of the CCM, as well as gaining a better understanding of health care providers’ and organizational perspective.

Peer Review reports


The prevalence of chronic diseases is globally on the rise, with cardiovascular diseases, respiratory disease, diabetes, cancer, and other chronic illnesses being major contributors to disability [1,2]. In Canada, two out of five people have at least one chronic disease. Chronic disease is a major driver of health care expenditure, reaching approximately $68 billion in Canada in 2010 [3]. The current health care system is oriented towards episodic and acute care, making it unprepared to address the multi-faceted and complex needs of those with chronic diseases [4,5]. Given the need for continuity, comprehensiveness and coordination, primary care has been suggested as potentially playing a central role in effective management and integration of care [6]. However, literature on current practice suggests that patients often receive inadequate care, with limited physician involvement in disease management, and little coordination and communication among care providers [7].

In response to these challenges and the call for redesigning care delivery for chronic diseases, Wagner and colleagues developed the Chronic Care Model (CCM) [8,9]. The CCM was developed to bridge the gap and translate knowledge between evidence-based chronic disease care and actual care practices. The framework which is centered in primary care, ‘conceptualizes care as prepared practice teams in productive interactions with informed, activated patients’ [10]. It posits six interrelated elements that are key to high quality chronic disease care: self-management support, redesigning delivery systems, decision support that is system wide, clinical information technology, linkages to community resources, and health care system organization [10,11]. The components seek organizational change at the systems’ level, promoting and delivering care that is evidence-based through using clinical tools such as guidelines, utilizing information systems that improve patient data sharing across the organization and between providers, engaging and empowering patients in their care, and mobilizing community resources to meet patient needs [11]. The CCM and its various components have been widely adopted and evaluated, with results showing that it improves patient care and clinical outcomes, and reduces care utilization and costs [12-16].

Despite the extensive evaluation of quality improvement (QI) initiatives, and research on CCM-based interventions, particularly across the United States, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake [10,14,17,18]. The model provides no clear blueprint on how each component can be implemented in practice, and there is considerable heterogeneity in the types of interventions implemented in primary care in support of the CCM [10]. Previous reviews synthesizing evidence on the CCM have focused on associated care changes, clinical outcomes and cost-effectiveness [10,14,19]. Although a recent systematic review by Holm and Severinsson identified barriers and facilitators of successful CCM implementation in primary care, it was specific to depression management in the US [20]. An understanding of the barriers and facilitators of implementing the CCM, in different care settings is important for several reasons. A barrier in this context is defined as any factor that hinders or impedes care change processes of CCM implementation. First, there are numerous contextual factors that enable organizational change and successful translation of evidence into practice [21,22]. Some of the factors previously identified include: evidence fit and relevance to the organizational context, staff relationships and collaboration, availability of resources, strong and committed leadership, and a culture supportive of change [22-24]. Second, given the complex and multifaceted nature of the model, primary care organizations can face difficulties with its implementation [12]. This is particularly the case given that there are no guidelines available on how to effectively operationalize CCM elements across different settings [25]. We therefore aimed to identify and review evidence on the challenges and barriers encountered while implementing the CCM in primary care.


We conducted a systematic literature review to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation. Barriers and facilitators were interpreted using the Consolidated Framework for Implementation Research (CFIR) [26]. As this research did not involve human subjects, we did not seek ethics clearance for the project.

Data sources

This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, PubMed and Scopus. These databases include Medline, EMBASE and the National Library of Medicine. The PubMed and Scopus search strategy used the following MeSH terms to describe ‘primary care’: primary health care, general practice and family practice. Since there were no MeSH terms for Chronic Care Model, the term was put under quotation marks during the search. In order to ensure a comprehensive search that included all studies that implemented the CCM, MeSH terms for ‘implementation’ were not used in the search. This strategy was also used to avoid excluding studies that might not have identified the term in their titles and abstracts. Search terms and concepts were combined using the Boolean and Proximity operator ‘OR’, while concepts were combined using ‘AND’ and ‘Near’ (Table 1).

Table 1 Key words used in search strategies

A second strategy adapted from Coleman and colleagues involved searching articles from Web of Knowledge Science Citation Index, which cited the five foundational CCM articles by Wagner and colleagues and Bodenheimer and colleagues [8-10,14,27,28].

In addition, hand searching of the reference lists in all articles that met the inclusion criteria outlined below was performed to identify any missed relevant articles. Search terms used in both search strategies are described in Table 1.

Study selection

Citations were downloaded and screened in Refworks, an online citation manager tool. Article abstracts and titles were read based on the exclusion and inclusion criteria detailed below. If the reviewer could not determine whether to exclude an article based on its abstracts and title, then it was retrieved for full text reading. Figure 1 displays the process involved in study selection.

Figure 1

Exclusion and inclusion criteria for article selection.

Exclusion criteria:

  1. 1)

    Articles published before 2003 and in languages other than English; this year was chosen as the search cut-off to follow the publication date of the last CCM foundational paper by Bodenheimer and colleagues [10], thus reflecting studies that implemented a more mature conceptualization of the model

  2. 2)

    Articles that solely described the CCM conceptually, i.e., did not report on an actual implementation of the model, commentaries and opinion pieces, study protocols, reviews including: systematic and narrative reviews, and meta-analyses

  3. 3)

    The target population of the study was not adults aged 18+ with chronic conditions

  4. 4)

    Articles arguing or providing the rationale for implementation of CCM in primary care, but which were not based on empirical studies.

Inclusion criteria:

  1. 1)

    Articles describing or evaluating the implementation of the CCM. Implementation had to refer to efforts which used change strategies to promote use of evidence-based practices or programs [29]

  2. 2)

    Implementation of the CCM had to occur in primary care, which is defined as integrated and accessible healthcare, delivered in the context of family and community [30].

  3. 3)

    Articles identifying barriers and/or facilitators of CCM implementation.

Data abstraction

The methods used for the study selection and data abstraction in this systematic review are aligned with those in the PRISMA statement. The PRISMA statement provides an evidence-based checklist intended to improve the standards of reporting in systematic reviews [31]. Given that the focus was on implementation, rather than study outcomes, not all aspects of the PRISMA statement were adopted. Data abstraction involved two stages. First, articles were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention.

The next stage of data abstraction involved qualitative analysis using the Consolidating Framework for Research Implementation (CFIR), which has five domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation [26]. It provides a conceptual framework which can be used to understand factors that influence successful implementation in health care, and is based on theories identified by Greenhalgh and colleagues’ widely cited systematic review [26,32]. The CFIR was selected because it includes multiple constructs and theories from peer reviewed studies on evidence-based knowledge dissemination and translation, organizational change and implementation, and uptake of research. It has also been suggested as a framework that can be used to guide the implementation of CCM components in interventions: therefore, it was deemed most appropriate for our study [26]. Table 2 provides summarized descriptions of the CFIR domains.

Table 2 Description of CFIR domains and constructs [26]

Using qualitative content analysis, implementation barriers and facilitators in 22 articles were mapped on to the CFIR framework. When articles described barriers or facilitators of CCM implementation, they were regarded as “attributive statements”, which were coded under the appropriate constructs and domains. These statements were often found in the discussion and results section of the articles. If the statement was beyond the domains and constructs of the CFIR, then it was still documented. Our approach was modeled after the data abstraction method used in a systematic review by Mair and colleagues [33]. The data abstraction and coding was performed by one reviewer. Interpretative and inductive reasoning were used to map out the attributive statements to the framework.


Twenty two studies were included in this review. Study descriptions and methodological procedures were summarized in terms of design, measurements, sample size and context, as shown in Table 3. In Table 4 statements reflecting implementation barriers and facilitators from each article were analyzed and coded to their respective domains and constructs under the CFIR framework.

Table 3 Overview of studies on the CCM in primary care
Table 4 Thematic analysis shows the barriers and facilitators identified by the studies mapped on to their corresponding CFIR domains and constructs


Networks and communication

Strong networks and increased communication between health care providers and organizations were fostered by collaboration across disciplines and specializations during care change processes [39,40,44,50,51]. Communication was reportedly supported by regular group meetings with supervisors and managers to discuss implementation issues, computerized information sharing and clinical assessment tools [41,45,52].


An organizational culture that promotes multidisciplinary, or patient centered care, was identified as important during implementation [45,51,52]. Support from clinical providers and the recognition of their importance in care change efforts was found to increase uptake of the CCM in primary care [35,37,39].

Implementation climate

Studies found that implementation climate was influenced by commitment and recognition for the need for change from the organization [40,45]. Willingness to advance and manage change was evident through incentivizing provider buy-in using financial reimbursement and work credit for project involvement [37,42,51].

Structural characteristics

Operationalization of CCM components was facilitated by health care providers, particularly specialists and non-physician staff such as nurse practitioners, who had to expand their responsibilities and scope of practice [45,53]. This sometimes required changing organizational policies and development of care teams to meet implementation needs [40,44].


Strong, committed and engaging leadership in the form of supportive administration and supervisors, with clear goals, was cited as a facilitator [40,45,50]. This included the appointment of an intervention champion to promote uptake of the model within the organizations [19,37,51]. Leadership roles were not limited to physicians, other health care providers such as nurse practitioners were found to play a major role in implementation [40].

Knowledge and beliefs about the intervention

Provider knowledge about CCM interventions was promoted through observing the execution process by other staff and education about project goals [42,50,51]. Strategies used to foster beliefs of the CCM effectiveness in care providers, particularly physicians, included demonstration of its benefits to their practice and sharing reports of patient improvements [37,51].



Many studies identified barriers related to executing intervention processes. Implementing the multiple components of CCM into practice created additional responsibilities for staff who were limited by time constraints [19,40,48,50]. Pearson & colleagues found that operationalizing the model elements at a high level of intensity, within a short time frame to be challenging [46]. Sustainability of the intervention was found to be difficult in some studies; in some instances, staff buy-in, an important aspect of implementation, was not enough to ensure program longevity [48].

Structural characteristics

Characteristics of the healthcare organization such as its size, whether it adopted a team-based approach and its flexibility in reorganizing care, were seen to influence the success of CCM adoption [40,45,48,52]. Institutional factors such as staff turnover and loss meant increased burden of responsibilities on existing providers [19,44] 10). Leadership turnover, particularly that of a medical director, was cited as a barrier towards implementing care change processes [38].

Readiness for implementation

Organizational readiness for the CCM was found to be impacted by the lack of interest and commitment from leadership and unavailability of resources for implementation [40,45]. Lack of resources that influenced readiness included low funding, lack of provider reimbursement strategies and low staff numbers [34,43,45,50].


Many studies found that execution of the intervention processes was challenging without support and accountability from senior leadership [19,20,44]. Without the presence of an intervention champion, endorsement of the CCM initiative was found to be limited in healthcare providers [19].

Knowledge and beliefs

Provider buy-in was greatly influenced by knowledge and beliefs about the intervention, particularly if they had misconceptions, were unconvinced of its effectiveness or lacked information [39,47,50]. Acceptance of the interventions by clinicians required time, and was also affected by the workload associated with implementing and executing the intervention components [45,50].


This review identified multiple barriers and facilitators of implementing the CCM across various primary care settings. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: culture of the organization, its structural characteristics, networks and communication, implementation climate and readiness, supportive leadership, and provider attitudes and beliefs.

Every primary care organization possesses its own cultural norms, practices and leadership. It is impossible to achieve change without adopting an approach that considers the individual and the team of providers, the organization setting and the greater system within which it is embedded [54]. Wolfson and colleagues attributed the success of QI in different primary care practices to facilitators in various levels of the organization including: presence of an initiative champion; physician, staff and patient cooperation; leadership investment; team practice and progress tracking [55]. The uptake of CCM elements in the studies required a primary care culture supporting willingness to change and quality improvement at the individual clinician, team and organizational levels. Implementation was most successful when there was a shared vision and a recognized need across the organization for new care change approaches to promote effective execution of the CCM [35,36,39,44,52].

Transforming care practices in an organization requires a supportive culture of change and learning [23]. Clinical provider beliefs and attitudes about evidence-based practice can influence the culture and learning environment, particularly when the provider perceives the evidence as unreflective of their day-to-day clinical decision making. This suggests the need to involve clinicians in early stages of intervention development and implementation [22]. Interventions that incorporated providers, patients and their experiences in the planning phase of the intervention were more successful in operationalizing the CCM [50,51]. This approach may bridge the cultural divide between leadership and clinical providers, which can hinder quality improvement efforts if left unaddressed. On the other hand, literature shows that lack of a group-oriented culture, as well as hierarchical relationships where the leadership is unsupportive of change, are negatively associated with implementation of care change processes [55]. Marshall and colleagues highlight the importance of culture and cultural change when implementing clinical governance in primary care. Cultural traits that support implementation efforts include commitment to accountability by the organization, willingness for collaborative work and learning, and ability to evaluate and reflect on mistakes [56].

Implementing and managing change processes in primary care can require time and flexibility. Organizational transformation can be slow and resistant to change, while spread of best-practice can be a challenge [57]. In some cases, even when an organization’s culture is supportive of the CCM, the inner structures of the primary care organization, such as a lack of staff and financial resources or a lack of clinician expertise, can impede organizational readiness for implementation and cause unexpected setbacks [34,48,52]. A study evaluating the implementation of evidence-based practice revealed that the current primary care system is not adaptive to rapid change, or accommodating to the additional duties associated with adopting new interventions. What this suggests is the need to set realistic implementation goals that are reflective of the organization and staff capacity for changes associated with the CCM. This requires comprehensive planning at all stages of component adaptation, to mitigate impeding factors such as rigid bureaucracies and organizational policies.

On the other hand, clinical leaders and champions can be drivers of change by ensuring the availability of resources and providing adequate staff supports [58]. Indeed, leadership support for change has been shown to be positively associated with QI outcomes and sustainability in primary care [24].

Implementation of CCM in primary care requires tailoring interventions to the local context, as well as altering the context, for the process to be successful. The two can co-adapt and evolve during the implementation process, thereby ensuring sustainability [59]. The majority of the studies included in the review identified the impact of the CCM on existing routines, practices, and culture of the organization. There was variability in how each organization adapted the CCM, i.e., translating the framework’s components into practice resulted in implementation heterogeneity. What became clear is that a standardized one-size-fits-all approach was difficult to put into practice when the components were conceptualized differently by each primary care organization.

Tailoring the intervention necessitates accounting for innovation-promoting and hindering factors at different levels of the organization, as well as reconfiguring aspects of the primary care setting itself [50].

This systematic review has several limitations. First, our search strategy meant that we did not assess: grey literature, studies that have not been published in peer-reviewed journals or those published in languages other than English; therefore, articles that were relevant to our review may not have been included. The search may have excluded studies that implemented CCM-based interventions but which were not explicitly referred to as such in the articles. In addition to the challenge of consistently identifying such studies, it would be difficult to be certain that implementation issues were reflective of issues relevant to the CCM. Another limitation is that the articles that were included were selected and assessed by one reviewer, thus limiting the reliability of the selected studies. Given that the articles were abstracted qualitatively by a single data abstractor, there is a possibility of bias in how the attributive statements were mapped under CFIR constructs and domains. While abstraction and coding was carried out by one reviewer, extensive and continuous discussion took place between both authors occurred during the study selection and data abstraction process. While using the CFIR as a guiding framework is a strength of our review, the numerous construct and sub-constructs meant that areas with few facilitators and barriers identified received less consideration (although these were captured in Table 4).


These findings highlight the need to evaluate factors that influence successful implementation of CCM in primary care. The CFIR can be used to guide the formative evaluation processes of CCM interventions. Assessment of organizational capacity and needs is important prior to and during the implementation of the intervention, in order to gain a better understanding of health care providers and organizational perspective. The barriers and facilitators identified under the CIFR domains can be used to build knowledge on how to adapt the CCM to different primary care settings.



Quality improvement


Chronic Care Model


Consolidating Framework for Research Implementation


Plan Do Study Act model


Guided Care Nurse


Community Health Center


Electronic Medical Records


  1. 1.

    World Health Organization. Innovative care for chronic conditions: building blocks for action, global report. Geneva: World Health Organization; 2002.

    Google Scholar 

  2. 2.

    World Health Organization. The global strategy on diet, physical activity and health. Geneva: World health Organization; 2002.

    Google Scholar 

  3. 3.

    Public Health Agency of Canada. Chronic diseases in Canada: United Nations non-communicable disease summit. Ottawa: Public Health Agency of Canada; 2011.

    Google Scholar 

  4. 4.

    Anderson G, Knickman JR. Changing the chronic care system to meet people’s needs. Health Aff. 2001;20(Supp 6):146–60.

    CAS  Article  Google Scholar 

  5. 5.

    Nolte E, McKee M. Caring for people with chronic conditions: a health system perspective. New York: McGraw-Hill International; 2008. p. 1–11.

    Google Scholar 

  6. 6.

    Rothman AA, Wagner EH. Chronic illness management : what is the role of primary care? Ann Intern Med. 2003;138 Suppl 3:256–62.

    Article  PubMed  Google Scholar 

  7. 7.

    Coleman K, Mattke S, Perrault PJ, Wagner EH. Untangling practice redesign from disease management: how do we best care for the chronically ill? Annu Rev Public Health. 2009;30:385–408.

    Article  PubMed  Google Scholar 

  8. 8.

    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20 Suppl 6:64–78.

    CAS  Article  Google Scholar 

  9. 9.

    Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74 Suppl 4:511–44.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288 Suppl 14:1775–9.

    Article  PubMed  Google Scholar 

  11. 11.

    Warm EJ. Diabetes and the chronic care model: a review. Curr Diabetes Rev. 2007;3 Suppl 4:219–25.

    Article  PubMed  Google Scholar 

  12. 12.

    Asch SM, Baker DW, Keesey JW, Broder M, Schonlau M, Rosen M, et al. Does the collaborative model improve care for chronic heart failure? Med Care. 2005;43 Suppl 7:667–75.

    Article  PubMed  Google Scholar 

  13. 13.

    Artz N, Whelan C, Feehan S. Caring for the adult with sickle cell disease: results of a multidisciplinary pilot program. J Natl Med Assoc. 2010;102 Suppl 11:1009.

    Article  PubMed  Google Scholar 

  14. 14.

    Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium. Health Aff. 2009;28 Suppl 1:75–85.

    Article  Google Scholar 

  15. 15.

    Cretin S, Shortell SM, Keeler EB. An evaluation of collaborative interventions to improve chronic illness care framework and study design. Eval Rev. 2004;28 Suppl 1:28–51.

    Article  PubMed  Google Scholar 

  16. 16.

    Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006;9 Suppl 1:1–15.

    Article  PubMed  Google Scholar 

  17. 17.

    Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health Serv Res. 2002;37 Suppl 3:791–820.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Rondeau KV, Bell NR. The chronic care model: which physician practice organizations adapt best? Healthc Manage Forum. 2009;22 Suppl 4:31–9.

    Article  PubMed  Google Scholar 

  19. 19.

    Chin MH, Cook S, Drum ML, Jin L, Guillen M, Humikowski CA, et al. Improving diabetes care in midwest community health centers with the health disparities collaborative. Diabetes Care. 2004;27 Suppl 1:2–8.

    Article  PubMed  Google Scholar 

  20. 20.

    Holm AL, Severinsson E. Chronic care model for the management of depression: Synthesis of barriers to, and facilitators of, success. Int J Ment Health Nurs. 2012;21 Suppl 6:513–23.

    Article  PubMed  Google Scholar 

  21. 21.

    Iles V, Sutherland K. Organisational change: a review for health care managers, professionals and researchers. In: National Coordinating Center for National Health Service Delivery and Organization. 2001. p. 12–68.

    Google Scholar 

  22. 22.

    Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 2004;13 Suppl 8:913–24.

    Article  PubMed  Google Scholar 

  23. 23.

    Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International J Qual Health Care. 2011;23 Suppl 5:510–5.

    Article  Google Scholar 

  24. 24.

    Newton PJ, Halcomb EJ, Davidson PM, Denniss AR. Barriers and facilitators to the implementation of the collaborative method: reflections from a single site. Qual Safety Health Care. 2007;16 Suppl 6:409–14.

    CAS  Article  Google Scholar 

  25. 25.

    Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O’Connor PJ. Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med. 2006;4 Suppl 4:310–6.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4 Suppl 1:50.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q. 1998;7 Suppl 3:56–66.

    Google Scholar 

  28. 28.

    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness- The chronic care model, part 2. JAMA. 2002;288 Suppl 15:1909–14.

    Article  PubMed  Google Scholar 

  29. 29.

    Fixsen DL, Naoom SF, Blase KA, Friedman RM. Implementation research: a synthesis of the literature. South Florida: Louis de la Parte Florida Mental Health Institute; 2005.

    Google Scholar 

  30. 30.

    Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. Primary Care: America’s health in a new era. Washington, D.C: National Academy Press; 1996.

    Google Scholar 

  31. 31.

    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6 Suppl 7:1–28.

    Google Scholar 

  32. 32.

    Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quart. 2005;82:581–629.

    Article  Google Scholar 

  33. 33.

    Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull World Health Organ. 2012;90 Suppl 5:357–64.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Barceló A, Cafiero E, de Boer M, Mesa AE, Lopez MG, Jiménez RA, et al. Using collaborative learning to improve diabetes care and outcomes: the VIDA project. Prim Care Diabetes. 2010;4 Suppl 3:145–53.

    Article  PubMed  Google Scholar 

  35. 35.

    Boyd CM, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47 Suppl 5:697–704.

    Article  PubMed  Google Scholar 

  36. 36.

    Boyd CM, Leff B, Sylvia M, Boult C. A pilot test of the effect of guided care on the quality of primary care experiences for multimorbid older adults. J Gen Intern Med. 2008;23 Suppl 5:536–42.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Graber JE, Huang ES, Drum ML, Chin MH, Walters AE, Heuer L, et al. Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives. Health Serv Res. 2008;43 Suppl 4:1403–23.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Haggstrom DA, Taplin SH, Monahan P, Clauser S. Chronic Care Model implementation for cancer screening and follow-up in community health centers. J Health Care Poor Underserved. 2012;23 Suppl 3:49–66.

    Article  PubMed  Google Scholar 

  39. 39.

    Henke RM, Chou AF, Chanin JC, Zides AB, Scholle SH. Physician attitude toward depression care interventions: implications for implementation of quality improvement initiatives. Implement Sci. 2008;3 Suppl 1:40.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med. 2006;4 Suppl 4:317–26.

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Johnson P, Raterink G. Implementation of a diabetes clinic‐in‐a‐clinic project in a family practice setting: using the plan, do, study, act model. J Clin Nurs. 2009;18 Suppl 14:2096–103.

    Article  PubMed  Google Scholar 

  42. 42.

    Kirsch S, Watts S, Pascuzzi K, O’Day MK, Davidson D, Strauss G, et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Safe Health Care. 2007;16:349–53.

    Article  Google Scholar 

  43. 43.

    Liebman J, Heffernan D, Sarvela P. Establishing diabetes self-management in a community health center serving low-income Latinos. Diabetes Educ. 2007;33 Suppl 6:132–8.

    Article  Google Scholar 

  44. 44.

    Lemay CA, Beagan BM, Ferguson WJ, Lee J. Peer reviewed: lessons learned from a collaborative to improve care for patients with diabetes in 17 community health centers, Massachusetts, 2006. Prev Chronic Dis. 2010;7 Suppl 4:1–9.

    Google Scholar 

  45. 45.

    Nutting PA, Gallagher KM, Riley K, White S, Dietrich AJ, Dickinson WP. Implementing a depression improvement intervention in five health care organizations: experience from the RESPECT-Depression trial. Admin Policy Mental Health Mental Health Serv Res. 2007;34 Suppl 2:127–37.

    Article  Google Scholar 

  46. 46.

    Pearson ML, Wu S, Schaefer J, Bonomi AE, Shortell SM, Mendel PJ, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. 2005;40 Suppl 4:978–96.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Reuben DB, Roth C, Kamberg C, Wenger NS. Restructuring primary care practices to manage geriatric syndromes: The ACOVE‐2 Intervention. J Am Geriatr Soc. 2003;51 Suppl 12:1787–93.

    Article  PubMed  Google Scholar 

  48. 48.

    Sanchez I. Implementation of a diabetes self-management education program in primary care for adults using shared medical appointments. Diabetes Educ. 2011;37 Suppl 3:381–91.

    Article  PubMed  Google Scholar 

  49. 49.

    Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med. 2006;4 Suppl 2:117–23.

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Sunaert P, Bastiaens H, Nobels F, Feyen L, Verbeke G, Vermeire E, et al. Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium. BMC Health Serv Res. 2010;10 Suppl 1:207.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Taylor D, Lahey M. Increasing the involvement of specialist physicians in chronic disease management. J Health Serv Res Policy. 2008;13 suppl 1:52–6.

    Article  PubMed  Google Scholar 

  52. 52.

    Walters BH, Adams SA, Nieboer AP, Bal R. Disease management projects and the Chronic Care Model in action: baseline qualitative research. BMC Health Serv Res. 2012;12 Suppl 1:114.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Watts SA, Gee J, O’Day ME, Schaub K, Lawrence R, Aron D, et al. Nurse practitioner‐led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits. J Am Acad Nurse Pract. 2009;21 Suppl 3:167–72.

    Article  PubMed  Google Scholar 

  54. 54.

    Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Quart. 2001;79:281–315.

    CAS  Article  Google Scholar 

  55. 55.

    Wolfson D, Bernabeo E, Leas B, Sofaer S, Pawlson G, Pillittere D. Quality improvement in small office settings: an examination of successful practices. BMC Fam Pract. 2009;10 Suppl 1:14.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Marshall M, Sheaff R, Rogers A, Campbell S, Halliwell S, Pickard S, et al. A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance. Br J Gen Pract. 2002;52 Suppl 481:641–5.

    PubMed  PubMed Central  Google Scholar 

  57. 57.

    Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. Br Med J. 2001;323 Suppl 7313:625–8.

    CAS  Article  Google Scholar 

  58. 58.

    Meredith LS, Mendel P, Pearson M, Wu SY, Joyce G, Straus JB, et al. Implementation and maintenance of quality improvement for treating depression in primary care. Psychiatr Serv. 2006;57 Suppl 1:48–55.

    Article  PubMed  Google Scholar 

  59. 59.

    Kirsh SR, Lawrence RH, Aron DC. Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes. Implement Sci. 2008;3 Suppl 1:34.

    Article  PubMed  PubMed Central  Google Scholar 

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We would like to acknowledge University of Waterloo librarian Rebecca Hutchinson for assisting us with developing a search strategy for the systematic review.

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Correspondence to Paul Stolee.

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The authors declare that they have no competing interests.

Authors’ contributions

MK and PS conceived of the paper. MK drafted the initial version and PS drafted revisions of this paper. Both authors read and approved the final manuscript.

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Kadu, M.K., Stolee, P. Facilitators and barriers of implementing the chronic care model in primary care: a systematic review. BMC Fam Pract 16, 12 (2015).

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  • Chronic care model
  • Chronic diseases
  • Primary care
  • Quality improvement
  • Intervention implementation
  • Organizational change