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

JGIM October 2010 Chronic Care and Education Supplement

Funded by the California HealthCare Foundation, and featuring guest editors Ed Wagner, David Stevens MD, and Judith Bowen MD, the October 2010 Chronic Care and Education Supplement to the Journal of General Internal Medicine is available in its entirety free of charge.

Building Blocks of Primary Care: Webinar featuring Thomas Bodenheimer MD

Thomas Bodenheimer, MD, professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine at UCSF, discusses the essential elements of primary care - the 10 "building blocks" - in a webinar produced for our PCT-LEAP project.

PBRN Workforce of the Future: Webinar recording

A July 2013 AHRQ webinar, “PBRN Workforce of the Future”, features MacColl Director Michael Parchman and Dr. Lyndee Knox of L.A. Net discussing the evolving workforce of the Practice-Based Research Network.  They focus specifically on the role of practice faciltators and research assistants in PBRN member practices in the context of quality improvement.  

Bundling Clinical Preventive Services: A Review of Definitions and Concepts from the Literature

Co-authored by MacColl researcher Karin Johnson, this AHRQ publication details an exploratory literature search that examines use of the term “bundling” in the context of clinical preventive services.  A number of gaps emerged, including potential challenges and benefits to bundling.

Team Meetings in a Clinical Environment Talk: San Francisco, 2009

A 10-minute presentation narrated by Ed Wagner and produced by The California HealthCare Foundation and the California Improvement Network shows how meetings can make a difference in team effectiveness and provides tips on getting the most from these group interactions.

Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis.

Co-authored by MacColl Director Michael Parchman, this March 2014 article examines the extent to which practice members' perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients' perceptions of the chronic illness care they have received.

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