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The incidence of chronic disease is increasing as the population ages.  Consequently, the Canadian health care system needs to implement systemic changes to manage chronic disease effectively.  This paper applies the six basic elements for improving chronic care found in Wagner’s Chronic Care Model (CCM) to the management of chronic kidney disease.  A fictional patient, Paul, is used to demonstrate the usefulness of this model in managing chronic diseases at a systemic and individual level.

Improving Chronic Kidney Disease Management using Wagner’s Model for Chronic Care