Summary: Maintaining good quality of life and health in face of living and/or aging with a chronic illness and/or disability can be challenging. The health care and related education and training of these individuals to become proactive partners in their ongoing care is the cornerstone of most chronic care models.

Findings: Social workers are not specifically mentioned in most chronic care models. However, as the health and social care processes can become complicated if the individual has barriers to partnering roles necessitated by chronic care models, a role for the social worker should be more clearly defined. Examination and application of the ecosystems perspective defines a clear role for social work to work collaboratively with other health professionals within a chronic care model.

Application: This paper explores how social work’s ecosystems model can interface with Wagner’s Chronic Care Model to fill the void that some individuals may experience in seeking and maintaining care to provide a useful framework to facilitate interventions within that model.