Adapting the chronic care model to treat chronic illness at a free medical clinic

Robert J. Stroebel, Bonnie Gloor, Sue Freytag, Douglas Riegert-Johnson, Steven A. Smith, Todd Huschka, Jim Naessens, Thomas E. Kottke

Research output: Contribution to journalReview articlepeer-review

36 Scopus citations


This pilot project was designed to determine the feasibility and effectiveness of an adaptation of the chronic care model applied to uninsured patients in a free medical clinic staffed by volunteer physicians. Of the 149 enrolled patients, 117 had hypertension, 91 had diabetes, and 51 had hyperlipidemia. Patients were enrolled in a chronic disease registry from March 1, 2001 through September 30, 2002 at the Salvation Army Free Clinic (SAFC). Two part-time registered nurses served as care managers providing disease-specific management using evidence-based guidelines. Consistent specialty consultation was available via phone, e-mail, or physician visit. Patient self-management was encouraged through collaborative goal setting. There were 40 patients lost to follow-up; 109 completed the study. A clinically significant improvement was obtained in at least one chronic disease for 79 patients. The chronic care model was a useful template for the delivery of effective chronic disease care to a group of uninsured patients at a free medical clinic.

Original languageEnglish (US)
Pages (from-to)286-296
Number of pages11
JournalJournal of Health Care for the Poor and Underserved
Issue number2
StatePublished - May 2005


  • Chronic disease
  • Diabetes
  • Hypertension
  • Medically uninsured

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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