Many patients now live with two or more chronic conditions

Due to the growing burden of chronic disease, our work increasingly involves looking for ways to support providers caring for patients who are managing several chronic diseases.  We are collaborating with AHRQ through its Multiple Chronic Conditions Research Network to understand interventions of the most benefit to complex patients.

We offer a proven strategy to help guide health systems change

The Chronic Care Model (CCM) provides an evidence-based framework to guide systems change.  More than 15 years after our development and dissemination of this framework via the Improving Chronic Illness Care program, the CCM continues to be utilized by health care organizations worldwide.

Our tools measure patient and provider experience

Our survey instruments were developed to be practical, readily-available and adaptable tools to help teams improve care for chronic illness -- but they've also been implemented for research purposes around the world.  The Assessment of Chronic Illness Care (ACIC) addresses care at the community, organization, practice and patient levels, and the Patient Assessment of Chronic Illness Care (PACIC) measures specific actions or qualities of care, congruent with the CCM, that patients report they have experienced in the delivery system.

Related Resources

Blog: Ed Wagner on meeting the demand for high-quality primary care

There is an ongoing debate in the United States about whether we will have enough primary care clinicians to meet the future demand for primary care and, if there is a shortage, how to solve it. But the debate misses a critical question: Are we meeting the current demand for high-quality primary care? Read more of Ed Wagner's December 2014 blog on the Insititute for Healthcare Improvement website.

A guide to research partnerships for pragmatic clinical trials

Based on insights from an initiative to accelerate pragmatic research, "A guide to research partnerships for pragmatic clinical trials" summarizes best practices for researchers and partners in healthcare systems as they establish collaborative relationships, develop research questions, and implement sustainable pragmatic clinical trials.

New Roles for Lay People in Primary Care: LEAP Webinar Series #5

With pressure to be more efficient and to introduce new types of interventions into care, practices are creating new roles for existing clinical team members and expanding the roles of team members with no prior clinical training.

Models of Complex Care Management: LEAP Webinar Series #2

Multiple chronic illnesses, combined with co-existing mental/behavioral health problems, along with frailty and functional limitations pose great challenges to the work of the busy primary care team.  The “Models of Complex Care Management” webinar was recorded in January 2014 and features the work of LEAP sites in Maine, Louisiana, Texas and West Virginia. This conversation asks how to build a system that supports the care of this population? How do we identify these patients?

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