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Facilitators and barriers of implementing the chronic care model in primary care: a systematic review
Open accessAbstract
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
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“Research papers more often tend to report clinical level variables (such as information given to patients to support self-management) than to assess organisational factors, such as professional culture, governance, financial management, communication patterns, implementation readiness, or presence of supportive leadership 35 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [35]
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“In other similar studies, positive effects have been shown for people with depression 34 35 , chronic obstructive pulmonary disease 35 , asthma 35 36 , diabetes 35 36 and heart failure 36 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [35]
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Keller, M. S., Guevara, N., Guerrero, J.-A., Mays, A. M., McCleskey, S. G., Reyes, C. E., & Sarkisian, C. A. (2024) · Figshare · doi:10.6084/m9.figshare.26944548
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545090
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545078
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545072
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545084
Trankle, S. A., Usherwood, T., Abbott, P., Roberts, M. M., Crampton, M., Girgis, C. M., Riskallah, J., Chang, Y., Saini, J., & Reath, J. (2020) · Figshare · doi:10.6084/m9.figshare.13064283
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545093
Lewinski, A. A., Shapiro, A. S., Gierisch, J. M., Goldstein, K. M., Blalock, D. V., Luedke, M. W., Gordon, A. M., Bosworth, H. B., Drake, C., Lewis, J. D., et al. (2020) · Figshare · doi:10.6084/m9.figshare.12197352
Piat, M., Wainwright, M., Sofouli, E., Vachon, B., Deslauriers, T., Préfontaine, C., & Frati, F. (2021) · Figshare · doi:10.6084/m9.figshare.14545075
Delameillieure, A., Vandekerkhof, S., Grootven, B. V., Wuyts, W. A., & Dobbels, F. (2021) · Figshare · doi:10.6084/m9.figshare.15179615
Delameillieure, A., Vandekerkhof, S., Grootven, B. V., Wuyts, W. A., & Dobbels, F. (2021) · Figshare · doi:10.6084/m9.figshare.15179612
Delameillieure, A., Vandekerkhof, S., Grootven, B. V., Wuyts, W. A., & Dobbels, F. (2021) · Figshare · doi:10.6084/m9.figshare.15179603
Trankle, S. A., Usherwood, T., Abbott, P., Roberts, M. M., Crampton, M., Girgis, C. M., Riskallah, J., Chang, Y., Saini, J., & Reath, J. (2020) · Figshare · doi:10.6084/m9.figshare.13064286
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Lewinski, A. A., Shapiro, A. S., Gierisch, J. M., Goldstein, K. M., Blalock, D. V., Luedke, M. W., Gordon, A. M., Bosworth, H. B., Drake, C., Lewis, J. D., et al. (2020) · Figshare · doi:10.6084/m9.figshare.12197364
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Lewinski, A. A., Shapiro, A. S., Gierisch, J. M., Goldstein, K. M., Blalock, D. V., Luedke, M. W., Gordon, A. M., Bosworth, H. B., Drake, C., Lewis, J. D., et al. (2020) · Figshare · doi:10.6084/m9.figshare.12197343
Leslie, M., Khayatzadeh‐Mahani, A., Birdsell, J., Forest, P., Henderson, R., Gray, R. P., Schraeder, K. E., Seidel, J. E., Zwicker, J., & Green, L. A. (2020) · Figshare · doi:10.6084/m9.figshare.13337710
Digital Health Systems in Integrated Care
Gray, C. S., Gagnon, D., Guldemond, N., & Kenealy, T. (2024) · Springer eBooks · doi:10.1007/978-3-031-25376-8_28-1
Roberti, J. E., Mazzoni, A., Guglielmino, M., Silva, C., Mazzaresi, Y., Falaschi, A., Hirschhorn, L. R., Parker, J., & García‐Elorrio, E. (2025) · Health Expectations · doi:10.1111/hex.70536
“Integrating PHC necessitates substantial changes in financing, management, and delivery of health services [14, 15].”
O’Flynn, J., McMorrow, R., Foley, T., Forde, R., McHugh, S., Newman, C., & Jennings, A. (2026) · Endocrine Practice · doi:10.1016/j.eprac.2026.02.006
Supporting Integrated Care through Visualization of Shared Medical Documents and Communication
Marref, R. (2023) · theses.fr (ABES) · doi:10.70675/1db4aef8z7294z4c7bzb0b1z000f40d4de6d
Haque, N. B., Lystad, R. P., Braithwaite, J., & Mitchell, R. J. (2026) · Journal of Health Services Research & Policy · doi:10.1177/13558196261454533
Metadata
- Authors
- Kadu, M. K., & Stolee, P.
- Affiliations
- University of Waterloo (CA)
- Corresponding author
- Stolee, Paul
- Venue
- BMC Family Practice
- Published
- 2015-02-06
- Volume
- 16
- Issue
- 1
- Pages
- 12-12
- ISSN
- 1471-2296 (ISSN-L)
- PMC
- PMC4340610
- OpenAlex
- W2006530818
- Cited by
- 204
- References
- 64
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 11 · 2023: 16 · 2022: 12 · 2021: 38 · 2020: 40 · 2019: 23 · 2018: 11 · 2017: 15 · 2016: 11 · 2015: 5
- FWCI
- 2.53
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Family Practice (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- University of Waterloo
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Family Practice › Primary Care and Health Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- Chronic Care Model, implementation barriers, implementation facilitators, primary care, chronic care, organizational culture, implementation climate, leadership, provider attitudes, organizational capacity
- MeSH terms
- Chronic Disease, Humans, Organizational Innovation, Patient Care Management, Primary Health Care, Organizational Culture, Models, Organizational, Needs Assessment, Quality Improvement
About these checks
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