Practice Facilitation Handbook

Table 6.2. Elements of the ACIC

Table of Contents


Component Content
Health delivery system
  • Organizational leadership in Care Model
  • Organizational goals for Care Model
  • Improvement strategies for Care Model
  • Incentives and regulations for Care Model
  • Senior leadership support of QI in Care Model
  • Benefits structure that supports patient engagement in Care Model
Community linkages
  • Patients are linked to outside resources
  • Practice partners with community organizations
  • Health plans coordinate guidelines, measures, and resources at practice level
Self-management support
  • Needs are assessed and documented
  • Support is provided to patients
  • Concerns of patients and their families are addressed
  • Behavioral interventions and peer support are provided
Decision support
  • Evidence-based guidelines are available through reminders and other methods
  • Specialists are involved in leadership roles in improving primary care
  • Provider education is provided for Care Model on issues such as population management and self-management support
  • Patients are informed about guidelines
Delivery system design
  • Effective practice teams deliver team-based care
  • Team leadership is clearly defined and empowered
  • Appointment systems support effective care
  • Followup is tailored and supports guideline followup
  • Planned visits are used for regular assessments, preventive care, and self-management support
  • Continuity of care is a priority and includes coordination of care across providers
Clinical information systems
  • Registry is used and tied to guidelines and provides prompts and reminders about services
  • Reminders to providers include information to team about guideline adherence at time of visit
  • Feedback is timely, specific to team, and aimed at improving team performance
  • Information about patient subgroups is given to providers to support planned care
  • Treatment plans are established collaboratively with patients
Integration of Care Model components
  • Patients are informed about guidelines
  • Registries include results of patient assessment and self-management goals developed with patient
  • Community programs provide feedback about patients’ progress
  • Practice uses data and feedback from teams to plan population care and self-management support programs and monitors success over time
  • Specific staff are charged with supporting routine followup
  • Team reviews guidelines with patient to guide self-management and behavior modification appropriate to patient goals and readiness

Adapted from Assessment of Chronic Illness Care (ACIC). Copyright 2000, The MacColl Center for Health Care Innovation, Group Health Cooperative.

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Page last reviewed May 2013
Page originally created May 2013
Internet Citation: Table 6.2. Elements of the ACIC. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.