Integrating Chronic Care and Business Strategies in the Safety Net (Toolkit)

Phase 3. Redesign Care and Business Systems

Key Change 3.1. Organize Your Care Team

Team care is at the heart of improvement and presents one of the biggest opportunities to improve practice efficiency. There are four key goals in rethinking primary care teams:

  • Ensure all of the needs are met in caring for the chronically ill.
  • Use the least expensive & best trained staff to perform each task.
  • Maximize patient and staff satisfaction and retention.
  • Standardize care, improving both quality and efficiency.

To achieve team-based care, an organization needs strong leaders willing to break down professional silos and clinicians willing to delegate tasks and assign roles and responsibilities for patient care to others on the team. Every staff person must be involved in the team and perceive their duties as improving the patient's experience of care.

Tom Bodenheimer, M.D., notes that physicians often try to perform all the clinical and self-management support functions necessary for effective patient care but are unable to do so as the burden of chronic illness increases. Bodenheimer emphasizes the need to delegate work to all staff, clinical and nonclinical. Nonphysician staff are more likely to adhere to protocols than physicians and therefore should be asked to engage in more of those care processes. Increasing staff involvement in patient care and creating a more cohesive care team increases both patient and team satisfaction, improving patient and employee retention.

One of the more efficient ways to begin developing a team is to:

  • Map out the existing care process for a specific clinical change (e.g. annual foot exams for patients with diabetes).
  • Determine which tasks aren't being completed or can be moved from "swamped" personnel to those more appropriate for the task.
  • Test how the new process works with the next patient scheduled.

Team members should be trained as needed. In addition, regular meetings are critical to solidify the team. These can be early morning huddles or scheduled time during the week to review cases, evaluate outcomes of ideas being tested, and modify roles and responsibilities.

Finance Tracks

Track 2. All finance tracks will want to organize the care team for efficiency, but track 2 will want to ensure that every visit has a physician involved.

Track 3. Track 3 can further optimize efficiency by using ancillary staff to conduct prework.

Hint: Standing orders can empower medical assistants and other ancillary staff to ensure that appropriate tests are conducted and available before a planned visit.

Actions Tools
Acquaint yourself with the concept of optimizing the care team. High functioning clinical teams are extremely efficient (presentation)29
Decide where to start. Project Planning Form (worksheet)30
Based on the key areas for improvement identified above, use process mapping to understand how care is delivered. Primary Care Practice High Level Flowchart (worksheet)31
Clearly assign roles and responsibilities to staff based on their capacities and licensure. Converting Guidelines to Practice (guide)32
Use PDSA cycles to generate and implement ideas on improved flow.

Plan Do Study Act Worksheet33

Plan Do Study Act Self-Management Support Example34

Conduct cross-training for staff where necessary/appropriate. Cross Train Staff (guide)35
Evaluate team function. Team Effectiveness Exercise (survey)36

Additional Resources

  • Improving Primary Care by Thomas Bodenheimer and Kevin Grumbach Chapter 9: Health Care Teams in Primary Care.
  • Online training on improvement teams is available at 

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Key Change 3.2. Clearly Define Patient Panels

Understanding your patient population is essential. If your practice does not have all patients paneled in some kind of electronic system, this will be your next major task. Creating patient panels helps to establish a linkage between a specific provider and his or her patients, a necessary prerequisite for quality measurement and improvement and many pay-for-performance programs. In addition, it enables the practice to assess the balance between patient demand and capacity.

Patient panels can help capture efficiency gains, especially if supply and demand are not properly matched. For example, once you can identify all your patients, you can begin to look at how the practice operates on a daily, weekly, and monthly basis. Knowing when you are likely to have heavy loads of chronically ill patients presenting or walk-ins allows you to schedule for these peak times.


  • Some practices already have this in hand, but if not, panel assignment is an essential first step.
  • Practices overwhelmed by demand should consider strategies for aligning supply and demand, first by maximally using the existing team. If this is insufficient, ensuring that all providers have reasonable panels by adding additional clinical staff may be indicated.
  • As you match patients and providers, ensure that you have up-to-date patient contact information. This will make it easier to contact patients for planned care visits described in section 3.4 below.
Actions Tools
Optimize the care team by assigning a panel of patients for each provider and manage panel size and scope of practice. Panels and Panel Equity (guide)37
Assess supply and demand to further optimize your team and ensure appropriate panel sizes.

Practice Supply worksheet38

 Daily Demand (guide)39

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Key Change 3.3. Create Infrastructure To Support Patients at Every Visit

The ultimate goal of care that follows the Chronic Care Model is for every interaction between the patient and the medical team to be productive. Whether the visit is acute or planned, the care for every patient needs to change if we hope to improve health outcomes. Practices can start by treating the next patient that comes through their door as a partner for whom the clinic is organized to support. Some elements of Chronic Care Model-based care that should be present at every visit—planned or acute—should be:

  • A deliberate focus on understanding and meeting patients' needs, including taking into account their treatment priorities. This can be accomplished through the creation and integration of a care plan.
  • An explicit effort to enhance patient's health literacy. This can be accomplished using teach-back techniques to ensure that patients understand what you have told them.
  • A perspective that any single interaction with a patient is part of an ongoing set of productive interactions where all of the patient's needs are being met. This can be accomplished by using each visit as an opportunity to engage the patient around the full array of medical needs including multimorbidities and depression, encouraging them to return for a planned visit when time is short.

Finance Tracks

All three financial tracks benefit from productive patient—provider interactions. This interaction is, after all, the source of all value in the health care system. Practices that ensure that patients truly understand their medication regimen, for example, greatly reduce errors and the resulting rework and poor outcomes associated with them.

When providers manage the total breadth of their patient's needs, rather than creating more work, efficiencies can be gained.

Track 3. Specifically, good integration of depression screening and management can directly increase revenues for track 3 practices, while dramatically freeing up time for primary care providers.

Track 1, Track 2, Track 3. Good mental health management can ensure that "15-minute visits don't turn into disorganized 45-minute visits," (Ann Lewis, CEO CareSouth Carolina, Curing the System May 2002). Such practices can dramatically improve efficiency for all three tracks. The CareSouth Carolina Story in the "Stories From The Field" section provides more details about their mental health work. In addition, the integration of case management activities into each visit increases the complexity of visits, increasing reimbursement opportunities.

Actions Tools
Create a patient care plan that captures the needs of the whole patient. Shared Care Plan (patient material)40
Reduce the health literacy demands made on patients.

Health Literacy and Patient Safety: Manual for Clinicians (guide)41 go to pages 18-40

Helping Patients Manage Their Chronic Conditions (online)42 go to pages 8-15

Utilize depression screening and care management to engage the whole patient.

Depression Management Tool Kit43 go to Appendix I, p. 17 (online)

Spanish PHQ-9 (survey)44

Additional Resources

  • The Center for Health Care Strategies has put together a set of fact sheets on health literacy that you may find interesting. They are available at
  • In addition to their Health Literacy manual, the American Medical Association has a number of other good health literacy tools, including a video available on their Web site: 

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Key Change 3.4. Plan Care

Now that you have some of the fundamental building blocks of Chronic Care Model-based care in place, you are ready to try delivering planned care. A planned visit is an interaction with a patient designed and organized to ensure that the care is consistent with guidelines. Prenatal and well-child visits are examples already in use. Planned visits are proactive, not patient initiated.

Many health care providers believe themselves to already be doing "planned" visits. They note that their patients with chronic conditions come back at defined intervals. Upon closer inspection, however, these visits may look a lot like acute care. The provider might lack necessary information about the patient's care needs; provider and patient might have different expectations for the visit; and staff may not be fully used to help with the organization of the visit and delivery of care. These "check-back" visits, while scheduled in advance, are often not efficient or productive for the provider and patient.

Finance Tracks

Finance tracks need to look closely at how proactive clinical care can improve business practices. For example, while a team member is ensuring that labs and screenings are up to date, they or others can verify coverage or eligibility for supplemental programs.

Track 2, Track 3. For fee-for-service tracks 2 and 3 with onsite labs, ensuring that all patients receive the recommended number of tests can dramatically increase revenue. The Mercy Clinic and the Point of Care A1c Testing stories in the "Stories from the Field" section demonstrate how real clinics used this concept to increase revenue.

In addition, the more complex and comprehensive nature of planned care visits enables sites to qualify for more robust evaluation and management (E&M) codes when they integrate the educational and counseling elements of the Chronic Care Model into practice. The Greenfield Clinic story illuminates this point.

Finally, once you have worked out how your team can best deliver planned care to individual patients, consider including group visits as part of your practice. Group visits benefit patients clinically and can benefit your center financially.

Track 2, Track 3. Fee-for-service tracks 2 and 3 can benefit by including a medical exam component and billing for each patient in the group.

Track 1. Track 1 can use nurses to conduct group visits as an alternative to phone or individual office consultations.

Additional Ideas to Help Make Efficient Planned Care a Reality

  • Use registry and guidelines as the informational basis for your planned care visit.
  • Integrate case management to improve efficiency and patient outcomes.
  • Fully use the team you developed as part of key change 3.1.
Actions Tools
Use planned interactions to support evidence-based care for individuals.

Organizing the Planned Visit (guide)45

System Changes and Interventions: Planned Care (presentation)46

Conduct visit preparation to ensure labs and screenings are up to date, & referral/specialty care information is available. Diabetes Standing Orders (worksheet)47
Patient priorities are elicited & available.

Open Access—Open Office (patient material)48

Shared Care Plan (patient material)49 go to page 3

Patient eligibility & insurance information is up-to-date. Front Desk Collections Flow Chart (guide)50
Teams have all the information they need at the time of the visit. Huddle Sheet (worksheet)51
Ensure that this more complex visit is being appropriately reimbursed. Getting Paid: Maximizing Collections (presentation)52
Try group visits.

Group Visit Starter Kit (guide)53

Group Visit Financials (worksheet)54

Additional Resources

  • Planned Care (streaming media), available at This video was produced by Improving Chronic Illness Care and demonstrates how planned care occurs within the context of a busy office. 

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Key Change 3.5. Assure Support for Self-management

To cope with their illness, patients living with chronic conditions must carry out complex treatment regimens, adjust everyday life tasks to accommodate their physical capacities, and deal with emotional responses to illness and loss. Because patients and families carry out much of the management of chronic illness, collaborative self-management support with patients is key to any effort to improve health outcomes. This effort can be seen both as a set of techniques useful in partnering with patients and as a cultural shift in the delivery of health care that places patients' goals, beliefs, preferences, and capacities at the center of care.

Creating informed, activated patients is particularly helpful when those patients have more than one chronic condition. When patients are informed and participate as partners in their care, they can provide valuable information to help their clinical team prioritize issues. Knowing patient preferences enables teams to have a realistic conversation about what self-care actions may best meet the patient's multiple needs. Other strategies the clinical teams can use to effectively partner with multimorbid patients include:

  • Helping all patients to engage in general preventive care, such as exercising, eating well, and quitting smoking.
  • Seeking out clinical "two-fers," where synergistically managing related chronic diseases results in positive outcomes for both, particularly in managing depression.

Providing necessary information, responding to patients' goals, and problem solving with patients to support continued improvement are central to self-management and can be part of every interaction between patients and the care team.

Finance Tracks

Track 1. Self-management is important for patient improvement in all three financial tracks. For practices in track 1, good support for self-management support can keep patients healthy, reducing their demand for frequent, low-intensity visits. Self-management support in conjunction with planned care also reduces costly emergency department visits, a key financial lever in integrated delivery networks.

Track 2, Track 3. Track 2 and 3 practices benefit because when patients do come in for a planned visit, that visit is often more complex.

Track 3. For those in track 3, self-management support by professionals such as Licensed Clinical Social Workers or Certified Diabetes Educators may be reimbursable.

Actions Tools
Empower patients to be responsible for their health. Helping Patients Manage their Chronic Conditions (online)55
Use the care team to work with patients collaboratively to:

  • Set realistic goals.
Understanding Goal Setting & Action Planning (guide)56
  • Create action plans.
Action Plan (guide)57
  • Follow up regularly to problem solve barriers and set new goals.
Agenda Setting Tool: Bubble Diagram (patient material)58
  • Share easy-to-read, culturally and linguistically relevant information with patients.
World Education (online)59
Explore resources in the community to support patient self-management. Diabetes Initiative (online)60

Additional Resources

  • The "5 A's" Behavior Change Model, a useful framework for organizing the infrastructure of self-management support. Check out the model by Glasgow et al and Whitlock et al.61
  • New Health Partnerships, , for those interested in self-management support. They are also developing a business case for self-management support.
  • Techniques for Patient Self-Management, available from the California Health Care Foundation at This video provides an overview of how to engage patients.
  • Improving Primary Care by Thomas Bodenheimer Chapter 5: Self-Management Support for People With Chronic Illness.

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Page last reviewed October 2014
Page originally created August 2008
Internet Citation: Phase 3. Redesign Care and Business Systems. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.