Practice Facilitation Handbook

Module 18. Using the AHRQ Care Model Toolkit With Practices

Table of Contents

To promote spread of the Care Model, the Agency for Healthcare Research and Quality (AHRQ) commissioned the development of a Care Model toolkit. The MacColl Center for Health Care Innovation, in partnership with RAND and the California Health Care Safety Net Institute, created Integrating Chronic Care and Business Strategies in the Safety Net. This “change package” is designed to help practices implement elements of the Care Model (AHRQ, 2008).

This Care Model toolkit can be a resource to both you and the practices you work with. The toolkit includes a recommended process for implementing the Care Model and links to tools that you and your practices can use to support those changes. It also includes recommendations for strengthening the financial status of practices while implementing the Care Model.

Contents of the Care Model Toolkit

Implementing the Care Model and Business Strategies in the Safety Net toolkit describes the specific practice changes involved in Care Model implementation. Practices are expected to go through each of four phases of Care Model implementation. Within each phase the 12 key changes do not need to be implemented in any particular order but should be pursued based on the needs of each practice. Table 18.1 lists the phases and key changes recommended in the toolkit.

Table 18.1. Toolkit phases and key changes contained in the Care Model toolkit

Phase 1: Getting Started

1.1 Organize your quality improvement team

1.2 Familiarize your entire team with key improvement strategies

Phase 2: Assess Data and Set Priorities for Improvement

2.1 Use data to set priorities

2.2 Select performance measures based on your needs assessment

2.3 Build performance measurement capacity

Phase 3: Redesign Care and Business Systems

3.1 Organize your care team

3.2 Clearly define patient panels

3.3 Create infrastructure to support patients at every visit

3.4 Plan care

3.5 Ensure support for self-management

Phase 4: Continuously Improve Performance and Sustain Changes

4.1 Reexamine your outcomes and make adjustments for continued improvement

4.2 Capture incentives based on quality of care

Each key change includes a table with specific action steps and associated tools. The Care Model toolkit includes links to more than 60 tools commonly used for quality improvement with the relevant changes, and example stories from practices that have made quality improvement pay.

How Should You Use the Care Model Toolkit?

You can use the Care Model Toolkit to:

  • Give you ideas for how to stage your work with practices.
  • Learn about what key changes are needed to implement the Care Model.
  • Gain exposure to a wide range of implementation tools.
  • Serve as a “training curriculum” for your practice.
  • Share parts of the toolkit with practices when working on those key changes.
  • Serve as a text or reference book to be used in conjunction with facilitation.
  • Train the practices to use the toolkit as a resource.

The toolkit, of course, does not cover every aspect of Care Model implementation. Furthermore, new tools are being developed all the time. Supplement the toolkit with additional materials depending on the needs of your practices.

Suggestions for Using the Care Model Toolkit With Practices

A demonstration project that used the toolkit with 18 community health centers provided insight into using the toolkit with practices:

  • Tip 1: The toolkit links users with tools through the Web. Because of the dynamic nature of the Web, URLs may have changed since publication of the toolkit. Test the links in the toolkit before you ask practices to use them.
  • Tip 2: Some of the links in the toolkit require registration to access. Let your practices know ahead of time when registration is required and that you have ascertained there is no charge to access the tool.
  • Tip 3: Make it easy for members of the practice to access the toolkit. Place an electronic copy of the toolkit on the computer desktops of key staff and clinician leaders at the practice for easy access. Use tablet readers and broadband cards if you want to make the toolkit accessible during your visit to a practice. Broadband cards can be a good way to go since many practices do not have wireless Internet or have firewalls that may block your access to the Internet when you are at the practice.
  • Tip 4: Select and use only those portions of the toolkit that meet the needs of each practice. The toolkit covers a wide range of topics and can be overwhelming to a practice in total. If your goal is to have practices use the toolkit on their own, introduce it to them gradually.
  • Tip 5: Pick and choose content to match the practice’s needs. Some of the content contained under each key change in the toolkit may not logically follow the change process your practice will undergo. Do not feel obligated to follow the steps and substeps outlined by the toolkit.


Agency for Healthcare Research and Quality. Integrating chronic care and business strategies in the safety net: a toolkit for primary care practices and clinics. Rockville, MD: AHRQ; August 2008. AHRQ Publication No. 08-0104-EF. Available at: Accessed April 10, 2013.

Page last reviewed May 2013
Page originally created May 2013
Internet Citation: Module 18. Using the AHRQ Care Model Toolkit With Practices. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.
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