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Chronic Care

/Chronic Care
Chronic Care2016-11-01T15:45:01+00:00

Chronic care models are designed to optimize the care of patients who have or are at significant risk for chronic conditions.  The prevalence of chronic conditions has been increasing due to the aging of the population and rising levels of lifestyle-related risk factors.   Projecting these trends forward, the growing burden of disease and costs could be crippling.  Consequently, chronic care improvement is a high priority for population health management.  The resources below provide ideas, insights, and promising practices for improving chronic care. These resources can be used to support collaborative learning and improvement in community models of care.

TitleAscending Link Source
Academy for Integrating Behavioral Health and Primary Care Learn more… Agency for Healthcare Research and Quality
Behavioral Health Innovations Learn more… AHRQ Innovations Exchange
Care Transitions Innovations Learn more… AHRQ Innovations Exchange
Chronic Care Innovations Learn more… AHRQ Innovations Exchange
Community Based Care Transitions Program Learn more… CMS Innovation Center
Empowering Patients Learn more… Robert Wood Johnson Foundation
Joint Principles for Integrating Behavioral Health into the Patient Centered Medical Home Learn more… American Association of Family Physicians
Oral Health Integration in the Patient Centered Medical Home (PCMH) Environment:
Case Studies from Community Health Centers
Learn more… Qualis Health
Patient Centered Medical Home Innovations Learn more… AHRQ Innovations Exchange
The Care Transitions Program Learn more… Eric A. Coleman, MD, MPH, University of Colorado, Denver, School of Medicine
The Chronic Care Model Learn more… Improving Chronic Illness Care
The Transitional Care Model Learn more… Dr. Mary Naylor and a multidisciplinary team of colleagues at the University of Pennsylvania
What We’re Learning: Engaging Patients Improves Health and Health Care Learn more… Robert Wood Johnson Foundation
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