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

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.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

This AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, considering the many needs of MCC patients as well as the contextual factors influencing service delivery. Reframeing processes and outcomes to include not only clinical care quality and experience, the model also incorporates patient health, well being, and quality of life issues.

Implementing the CCM in Academic Environments

The materials in this toolkit were created for two collaboratives designed to help implement the Chronic Care Model in academic health care settings:  one nationally, the other focused on California-based institutions. 

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