Improving care for the chronically ill is one of the most pressing health needs of our time. To help more safety net organizations implement the Chronic Care Model effectively and sustainably, the Agency for Healthcare Research and Quality (AHRQ) contracted with Group Health's MacColl Institute, RAND Health, and the California Health Care Safety Net Institute (SNI) to develop a toolkit. The toolkit informs safety net providers on how to redesign their systems of care along the lines of the Chronic Care Model while attending to their financial realities.
The toolkit provides a step-by-step practical approach to guide primary care teams through quality improvement. The toolkit:
- Sequences and describes the specific practice changes involved in Chronic Care Model implementation.
- Integrates strategies designed to improve the business case for quality improvement.
- Links more than 60 commonly used quality improvement tools with the relevant changes.
- Includes examples from practices that have made quality improvement pay.
A practice coaching manual is also available as a companion piece to this toolkit.
Purpose of This Toolkit
Need To Improve Chronic Illness Care
The Chronic Care Model as a Guide for Change
How To Use This Toolkit
Phase 1. Getting Started
Key Change 1.1. Organize Your Lead Quality Improvement Team
Key Change 1.2. Familiarize Your Entire Team With Key Improvement Strategies
Phase 2. Assess Data & Set Priorities for Improvement
Key Change 2.1. Use Data To Set Priorities
Key Change 2.2. Select Performance Measures Based on Your Needs Assessment
Key Change 2.3. Build Performance Measurement Capacity
Phase 3. Redesign Care and Business Systems
Key Change 3.1. Organize Your Care Team
Key Change 3.2. Clearly Define Patient Panels
Key Change 3.3. Create Infrastructure To Support Patients at Every Visit
Key Change 3.4. Plan Care
Key Change 3.5. Assure Support for Self-management
Phase 4. Continuously Improve Performance and Sustain Changes
Key Change 4.1. Reexamine Your Outcomes and Make Adjustments for Continued Improvement
Making Changes in Practice
The Business Case for Quality Improvement
Key Change 4.2. Capture Incentives Based on Quality of Care
Advanced Topics: Tackle Operational Barriers to Improved Patient Care
Stories from the Field
Point-of-Care Hemoglobin A1c Testing at the Medical College of Wisconsin
CareSouth Carolina Integration of Behavioral Health Services
Economic Impact of Chronic Care Model Implementation at Mercy Clinics
Reduced Hospitalizations in the Univera System
Appendix A. The Evidence Base for the Chronic Care Model
History of the Chronic Care Model
Learning from Experience: The Case for a Toolkit
Appendix B. Partner Tools
Prepared by Group Health's MacColl Institute for Healthcare Innovation, in partnership with RAND and the California Health Care Safety Net Institute, under Contract No./Assignment No: HHSA2902006000171.