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

A Toolkit for Primary Care Practices and Clinics

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 a 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
    Making Changes in Practice
    The Business Case for Quality Improvement
    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
    Key Change 4.2. Capture Incentives Based on Quality of Care
Advanced Topics: Tackle Operational Barriers to Improved Patient Care
Stories from the Field
    GreenField Health
    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
Reference List
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.

Page last reviewed October 2014
Page originally created August 2008
Internet Citation: Integrating Chronic Care and Business Strategies in the Safety Net (Toolkit). Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.