Using the Chronic Care Model for Health System Change

Asthma Health Disparities Collaborative Coalition Guide

Tools and Other Resources 

The Health Disparities Collaborative features FQHCs testing, sustaining, and spreading health system changes in all six of the Chronic Care Model components. Implementation of the HDC over the past several years has provided an extensive pool of examples, tools, and resources that those new to the effort are free to use or modify. In addition, the Asthma Initiative of Michigan, the asthma coalitions, and other asthma-related organizations contribute a wealth of asthma-related tools and resources.

By examining the HDC resources and those from the asthma world, asthma coalitions and FQHCs can draw upon what is available, select what they believe will work best, make any necessary modifications, and go forward with their work with the Asthma HDC. Table 2 provides a sample list of potential health system changes and associated resources.

Case Studies/Other Ideas

Below is presented a health center case study for each of the six Chronic Care Model components. Additional ideas of health system changes—as identified in the literature, presentations, case studies, and other resources—are also included (go to Table 2 for some of these resources). Collectively, these provide asthma coalitions and FQHCs with practical options for identifying potential health system changes and developing PDSA cycles. The examples presented below are not meant to be prescriptive because each FQHC will require an approach that is unique to its current environment and clientele. Appendix E presents additional findings from studies on the Chronic Care Model.

Health care organization. Hill Health Center in New Haven, CT generated a significant amount of media support for the center's newly developed pediatric asthma program that, in turn, generated internal pride among administrators, providers, and staff. This recognition resulted in renewed commitment and support by the center's administration for the efforts to improve asthma care specifically and chronic care overall.

In addition to this case study example, other ideas for consideration include the following:

  • Involve the senior leader in developing an aim statement or ask the senior leader for feedback on the draft statement.
  • Gain the senior leader's interest with reports and feedback.
  • Involve the senior leader in marketing the outcomes in the community for partnership development.
  • Have the senior leader, physician champion, or team leader regularly report progress and results to Board of Directors:
    • Provide a straightforward report that everyone can understand; avoid technical and clinical jargon.
    • Provide patients' own words or reactions, whenever possible, or discuss provider satisfaction.
  • Place storyboards in places visible to staff and patients.
  • Have physician champion share tested tools and interventions at provider meetings to engage interest and involvement to prepare for the efforts to sustain and spread.
  • Choose a physician champion with the following characteristics:
    • Commitment to improve/change the system.
    • Ability to articulate needs of team without alienating others.
    • Willingness to be a team member.
  • Enlist the person responsible for quality in the organization as a team member.
  • Orient new clinicians to the collaborative—develop an orientation format for training clinicians who will be newly joining the collaborative.

Self-management support. La Casa-Quigg Newton Clinic in Denver, CO scheduled planned visits at specific intervals, depending on the patient's asthma severity, and devoted a large part of these visits to education about patient self-care. In addition, outreach workers conducted followup on missed appointments.

In addition to this case study example, other ideas for consideration include the following:

  • Have patients bring materials and asthma management tools (inhalers, spacers, and peak flow meters) with them to every visit for review of use and technique.
  • Use group visits and social support group visits in disease self-management programs.

Delivery system design. G.A. Carmichael Family Health Center in Canton, MS linked with the respiratory therapy department of local community college to contract with students to provide asthma education to patients at a school-based clinic. The college students assisted patients with creating scrapbooks, thereby eliciting personal, individual feelings and concerns about asthma along with teaching them self-management skills and emphasizing the importance of goals.

In addition to this case study example, other ideas for consideration include the following:

  • The care team reviews charts at beginning of day, considers what each patient needs and divides the tasks among the team members.
  • Make pre-visit phone calls.m Remind patients of visit; talk about self-management goals, see how they are doing; ask them to bring medications; identify what you will be discussing tomorrow and see if there is anything they would like to specifically address.
  • Define roles and distribute tasks among team members. Define and develop the team as a unit. Determine process for care and assign team members to tasks. Match the work to the individual's licensure and capability. Cross train staff and use protocols and standing orders for care. Determine back-up staff for each task.
  • Use planned interactions to support evidence-based care. Use one-on-one visits to review current status, deliver evidence-based services and optimize disease control; use group visits to deliver care to interested patients; predict clinical needs of patients (using clinical information systems):
    • Invite patients with chronic care needs in for a planned visit.
    • Use registry to proactively contact patients for followup.
    • Have nurses do stepped protocols for appropriate patients.
    • Have nurses do self-management support for patients in need of self-monitoring skills.
    • Inform patients of visit agenda at beginning of visit; check to see if it meets their expectations.

Decision support. Franktown Community Health Center in Franktown, VA integrated the National Asthma Education and Prevention Program asthma guidelines into the care process. In addition to providing technical assistance, consultation, and collaborative care, an asthma specialist and her colleagues held an educational session for providers, clinical staff, and school nurses. Guidelines are now incorporated into all visits, posted in exam rooms, and highlighted in quarterly newsletters.

In addition to this case study example, other ideas for consideration include the following:

  • Laminate logarithms and put on wall in exam rooms.
  • Use structured assessment/encounter form to diagnose and determine severity of all patients as well as guide decisionmaking.
  • Use flow sheets, pathways, or checklists to embed guidelines into daily practice.
  • Use an asthma assessment form that is easy to follow which includes all selected measures, and provides medical staff with pertinent medical information when assessing asthma patients.
  • Integrate depression screening if warranted.

Clinical information systems. Prairie Community Health in Isabel, SD began a monthly conference call with the team to review registry numbers and the progress the team was making toward their aim. A data comparison was made between participating and nonparticipating providers to "gently prod" nonparticipating providers to become involved.

In addition to this case study example, other ideas for consideration include the following:

  • Develop a consistent, methodical process in writing to assure that all data are entered into the registry. Train appropriate staff and volunteers.
  • Keep manual data entry to a minimum. Whenever possible, transfer information electronically from systems like appointments and billing.
  • Schedule and produce reports to care team, managers, asthma coalitions, Asthma Initiative of Michigan, and others.
  • Before a patient visit, print out current information from the registry. Determine a process of how to identify patients that are scheduled for a visit which ensures this information is printed and included on the patient chart at time of visit.
  • Periodically generate a list of patients who are missing a service or have a service that is overdue.
  • Use the registry to generate lists of high-risk patients for specialized care and followup (e.g., smokers, recent ED visits).
  • Divide the population of asthma patients into categories (e.g., ethnicity, language, insurance, needs/limits, homelessness, etc.) to identify and respond to special needs.
  • Conduct monthly identification of poorly controlled asthma via billing data for hospitalizations, ED visits, medication use/misuse, and no-shows for outpatient visits.

Community resources and policies. Ben Archer Health Center in Hatch, NM negotiated a reduced price for peak flow meters from the manufacturer and contacted pharmaceutical companies for support with educational materials. The center used community outreach workers to provide training on triggers in the home and worked with a local hospital to provide self-management support. Other center efforts included working with:

  1. The local health department and American Lung Association to provide training to health educators, community health workers, and community leaders.
  2. School administrators to develop new policies for prescription use and treatment at schools.
  3. A local pharmacy to put reminders with any metered dose inhaler or asthma medication for patients to follow up with their primary care provider.

In addition to this case study example, other ideas for consideration include the following:

  • Create a list of resources and develop a resource notebook or computer database of resources.
  • Contact local library for available resources on asthma.
  • Enlist support of pharmacies in noting too frequent refills of metered dose inhalers for beta agonists.
  • Find sources for interpreters to assist with education, training materials, etc.
  • Share successes and challenges with partner organizations.
  • Request funding from service organizations for specific items, equipment, or services
  • Develop a communication plan between school nurses and the primary care team for a written asthma action that includes timely and ongoing feedback
  • Develop and distribute asthma educational materials so that children and parents receive consistent information both at school and from their physician.

Return to Contents

Evaluation and Spread

Evaluation Tools

The Asthma HDC process and outcome measures are the primary mechanism used by the FQHCs to track the changes resulting from their health system improvements. Other mechanisms may be used to complement these evaluation efforts, including the following:

  • Documentation of PDSA cycles—Sample forms are presented in Appendix F.
  • Team Assessment Tool—This 23-question document is used to evaluate teams participating in any Health Disparities Collaborative. It can be downloaded at:
  • Assessment of Chronic Illness Care, Organizational Assessment—This written assessment to measure organizational support for implementing the Chronic Care Model can be downloaded at:
  • Patient Assessment of Chronic Illness Care—This written assessment to measure the health center's support for implementing The Chronic Care Model from the patient' viewpoint can be downloaded at:

Spreading and Sustaining Change

After a FQHC has tested a health system change that was found to be successful, the next step is to spread and sustain the change with other providers in the health centers as well as with other health centers. Before moving forward with this step, though, it is best for the FQHC to assess whether or not it is ready to successfully spread to another provider, chronic disease, or site. The Health Disparities Collaboratives Web site ( has a tool that can help the FQHC examine key issues and improve its current work plan. The tool requires organizations to answer 10 questions using a 5-point scoring scale. For each question, there are discussion points, recommendations, and a space to record an action plan.

Massoud and colleagues point out that how well health care providers and their organizations are able to spread new ideas and innovations is critical in closing the gap between best practice and common practice.n Asthma Coalitions and FQHCs are strongly encouraged to review this concept as they move to spread and sustain their changes.

Other helpful tips on how to assure that health system changes are maintained include:

  • Establish and document standard processes (document the flow of the new process).
  • Make changes to job descriptions, policies, procedures, and forms.
  • Address supply, equipment, and design issues.
  • Use measurements and audits. Use data to monitor the success of the change and the spread; avoid slippage.
  • Pay attention to orientation and training (Provide training to existing staff and incorporate into ongoing orientation of new staff.).
  • Assign ownership; that is, determine who is responsible for day-to-day ownership and maintenance work of new process.
  • Hold senior leaders accountable for the efforts to sustain and spread the change and remove inhibitors that might allow slippage back to the old system.
  • Address the social aspects of change (appreciation, publicity and praise, resistance, etc.)j:
    • Provide information on reasons for the change.
    • Empathize with anxiety; do not expect to eliminate it.
    • Show how change supports the organization's aim.
    • Put it in historical perspective.
    • Link to needs of patient/family/community.
    • Reframe as opportunity.
    • Provide mechanism for questions/comments.
  • Provide specific information on how the change will affect people:
    • Share results from testing.
    • Be prepared for questions.
    • Study rational objections and be prepared to address them.
    • Include members of team who tested in presentations.
  • Get consensus on resources and other support for implementation:
    • Define plan with milestone and dates.
    • Ask leaders and key people to publicly support.
    • Express confidence in those asked to carry out change.
  • Publicize the change:
    • Use symbolism, stores, pictures, etc.
    • Summarize key points and agreements as made.
    • Show appreciation for those developing and testing change.
    • Take advantage of significant events (crisis, inspection, complaint) and tie to implementation.

The Asthma Initiative of Michigan is currently working on developing a plan for 2007-2008 that involves regular conference calls among the coalitions and FQHCs. Each call will focus on a different aspect of the Chronic Care Model or another specific issue or item. Using a focused-format will facilitate in-depth conversations, increasing the likelihood that coalitions and FQHCs can learn from one another.

Return to Contents

A Final Word

To facilitate changes in the systems of asthma care, especially among health care providers who serve populations experiencing the highest asthma health disparities, the Asthma Initiative of Michigan developed and is implementing a decentralized Asthma Health Disparities Collaborative) model. Using its existing infrastructure of regional and local asthma coalitions, Michigan's FQHCs are being encouraged to implement the Asthma HDC—an evidence-based initiative that reaches the most vulnerable populations. This guide provides the coalitions and the FQHCs with the scientific and background information, practical examples, tools, and resources to help them make health system changes that will improve quality of care for Michigan residents with asthma.

Return to Contents


The author would like to acknowledge the assistance of Dona Goldman and the Rhode Island Department of Health. The author, the Michigan Asthma Program, and several asthma coalitions participated in the Rhode Island Faculty Workshop on the Chronic Care Model and the Model of Improvement. This 2006 workshop, sponsored by the Agency for Healthcare Research and Quality, provided information that greatly enhanced the development of this guide.

m A sample script that can be adapted when telephoning patients to schedule a visits available on the Improving Chronic Illness Care Web site at:
n Massoud MR, Nielsen GA, Nolan K, et al. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. Available at:

Return to Contents
Proceed to Next Section

Page last reviewed September 2007
Internet Citation: Using the Chronic Care Model for Health System Change: Asthma Health Disparities Collaborative Coalition Guide. September 2007. Agency for Healthcare Research and Quality, Rockville, MD.