The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. In a well-designed delivery system, clinicians plan visits well in advance, based on the patient’s needs and self-management goals. During "group visits," patients see their clinician and meet with other patients with similar health problems. Nonphysician staff are cross-trained to provide care via standing orders.

Effective management of chronic illness requires more than simply adding interventions to an existing system focused on acute care. Rather, it necessitates basic changes in delivery system design. These changes require a shift of emphasis to "planned" visits instead of acute visits. Effective management often requires expansion of staff member roles and responsibilities. These changes include all professionals (e.g., nurses, health educators) who have the knowledge and time to carry out the range of tasks required to manage complex chronic conditions. Staff members also need timely access to key clinical data, enough time to interact with patients, and regular, planned follow-up with patients. Meeting these needs often requires innovation in the scheduling and organization of care, such as group or individual planned visits.