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

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. 

Academic Medical Center Collaborative Tools

The Association of American Medical Colleges facilitated the adoption of the Chronic Care Model by academic medical centers through two collaboratives based in educational institutions: one national, and one focused on California institutions.  Find eac collaborative's training materials here.

Breakthrough Series Collaboratives tools

These Improving Chronic Illness Care tools were created for The Breakthrough Series Collaboratives, with the specific purpose of preparing for and conducting a regional collaborative health care improvement effort.

Multiple Chronic Conditions

We provide technical assistance to the AHRQ Multiple Chronic Conditions Research Network, which aims to support patients living with at least two chronic conditions.  Watch a short video about complex patients, and review an infographic on the importance of this research area.

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