Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Providers receive ongoing education, and primary care clinicians stay in the loop when a patient is referred to a specialist.

Effective chronic illness management programs follow explicit guidelines or protocols, preferably evidence-based guidelines. Reminders, flow sheets/progress notes, provider education materials and sessions, appropriate input and collaborative support from relevant medical specialties, and patient participation are all part of a process to implement evidence-based guidelines in the clinical setting.