Chronic Conditions - Key Activity 1


Convene a Multidisciplinary Implementation Team for Chronic Care Management


This key activity involves all seven elements of person-centered population-based care: : operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity provides guidance for senior leaders to identify the right individuals within your practice who will be responsible for planning and implementing the key activities in this guide and overseeing related quality improvement and equity efforts, as outlined in Appendix A: Sample Idealized System Diagram: Weaving Measurement and Learning Into Practice Operations. This section also provides guidance on how to support and sustain this team to foster success.

The implementation team members are a diverse group of individuals who are champions for advancing this work. Improving your practice’s key outcomes for each population of focus and reducing equity gaps require the aligned efforts of all care teams and nearly all functional areas of the practice, not just those working directly with patients.

This team is responsible for ensuring that all foundational key activities in this guide, including those related to screening for social needs, are implemented. When identifying potential members of this multidisciplinary implementation team, the practice should identify a diverse group of staff who are reflective of various job functions within the practice, the local community and, by extension, the lived experience of patients. In addition to implementing Key Activity 4: Use a Systematic Approach to Decrease Inequities Within the Population of Focus, the team should apply an equity lens to every step outlined in this guide to help ensure that any improvements are equitably spread among the patient population. To achieve optimal functioning and impact, all members of this diverse multidisciplinary team should have their perspectives proactively included.

Relevant HIT capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management/care coordination (see Appendix E: Guidance on Technological Interventions). To enable team coordination, thought must be given to how access to relevant technology and how data capture can be distributed, consistent and integrated into workflows, and how data is accessible across team members. Where possible, it is desirable to avoid duplication of data entry, siloing of information in standalone applications and databases, and the need to work in multiple applications that require separate login.

Action steps and roles

1. Convene a time-limited group of practice leaders.

Suggested team member(s) responsible: chief medical officer (or equivalent), office manager or QI coordinator.

Start with a small group of leaders from your practice (some of whom will be on the implementation team) who can help refine the “charge” or scope of work of the implementation team and both identify and engage the people/roles that will be required to implement the scope of work of the team.


2. Develop a preliminary scope of work or charge outlining the responsibilities of the implementation team.

Suggested team member(s) responsible: time-limited group of practice leaders.

This scope or charge includes but may not be limited to enabling, aligning, leveraging and supporting the planning and implementation of all foundational activities in this implementation guide so that the practice meets the foundational competencies for chronic conditions. This should include a tentative timeline, core activities, and key roles and responsibilities.

However, there may be further foundation-building work needed at your practice in order to succeed at the above key activities. The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multidomain assessment that is used to understand current population health management capabilities of primary care practices. This self-administered tool can help your practice identify opportunities and priorities for improvement.

If your practice does not score highly in the domains of leadership and culture, the business case for population health management, technology and data infrastructure, or empanelment and access, consider implementing the activities listed in the four guides on Building the Foundation before or in parallel to working on key activities related to management of chronic conditions.


3. Identify leadership and key actors for the implementation team.

Suggested team member(s) responsible: time-limited group of practice leaders.

The multidisciplinary implementation team should include those empowered to make changes in workflows, policies and staff assignments. They should be respected influencers in the organization (early adopters), who can also guide the change management process. They should include those with expertise in partnering with patients with diabetes and hypertension management.

  • Appoint a “champion” or lead person (e.g., chronic conditions care coordinator or diabetes care coordinator) to oversee the implementation and coordination of the team.
  • Identify key staff who will be the core members of the implementation team. These people will likely include one or more panel managers, clinicians, nurses, administrators, data analysts, social workers, community health workers, and other community outreach staff, information technology (IT)/electronic health record (EHR)-related personnel, and human resources personnel.
  • For the chronic conditions multidisciplinary team, it is important to include members of the clinical team, patient support team, outreach team, social support team and EHR/data team. This could include a core team and an expanded team. Potential members include:
    • Adult/family primary care clinicians (medical doctor, doctor of osteopathic medicine, advanced practice registered nurse, physician assistant).
    • Endocrinologist.
    • Cardiologist.
    • Registered dietician.
    • Certified diabetes educator.
    • Nurse.
    • Medical assistant (MA) or licensed vocational nurse (LVN).
    • Social worker.
    • Care coordinator.
    • Community health worker.
    • Pharmacist.
    • A member of the IT or EHR team (as part of the expanded team).
    • QI lead.
    • Billing manager or similar (as part of the expanded team).
    • A frontline staff member who interfaces with patients by phone and at check-in.
  • Invite identified people to become part of the implementation team and ensure that they have appropriately designated time for participation.
  • Teams should engage representation from IT to support the work of pulling data from the EHR and embedding updated data into tracking and evaluation.


4. Launch the implementation team and set it up for success.

Suggested team member(s) responsible: clinical coordinator or chief operating officer or chief medical officer.

This work includes:

  • Ensuring that the team understands its charge or scope of work by developing a Multidisciplinary Implementation Team Charter Template, that outlines this work. Groups should work with each other to establish rapport and psychological safety as they develop team norms, which help teams to work together effectively.
  • Defining roles and responsibilities, including the anticipated commitment (in hours) on a monthly basis.
  • Establishing a meeting structure, file structure and communications structure to support effective, efficient work.
  • Dedicating time and effort to forming, storming, norming and performing as a team. The Team Communication and Working Styles Template is one tool that team members can complete and share with other teammates to accelerate this process.
  • Understanding baseline data related to outcomes of interest (e.g., hypertension control rates, hemoglobin A1c control rates), along with data related to known and perceived barriers to these outcomes.
  • Prioritizing elements within the scope of work, informed by baseline data and identified population needs.


5. Develop a simple yet robust measurement strategy and learning system to guide your improvement efforts.

Suggested team member(s) responsible: implementation team.

A learning system enables a group of people to come together to share and learn about a particular topic, to build knowledge, and to speed up improved outcomes. A measurement strategy and learning system:

  • Contains a balanced set of measures looking at outcomes, processes and possibly unintended secondary effects (e.g., increased cycle time and impact on team well-being).
  • Incorporates the patient perspective and the perspective of staff (front desk and others), care team members, providers and management.
  • Allows the team to determine if the process or system has improved, stayed the same or gotten worse.
  • Helps guide improvement efforts and informs practice operations. See Appendix A: Sample Idealized System Diagram: Weaving Measurement and Learning Into Practice Operations for a sample system diagram of how your measurement strategy can be used to support practice operations.

Your practice should track the core and supplemental measures for hypertension control, comprehensive diabetes management and preventive ambulatory care visits. These can be considered outcome measures because there is ample evidence that improved care and management of chronic diseases will improve overall population health outcomes for effective chronic disease management.

In addition to the core and supplemental measures, practices should track process measures and balancing measures. Appendix C: Developing a Robust Measurement Strategy describes and defines the key milestones in the development of a robust measurement strategy, including definitions for each of these terms.

Suggested process measures:

  • The percentage of patients 18 to 75 years of age with diabetes (type 1 and type 2) who receive a hemoglobin A1c test during the measurement year (NQF 0057).
  • Percentage of patients ages 18 or older who are screened for high blood pressure and, if elevated or hypertensive, have a follow-up plan documented (CMS22v12).
  • Percentage of adults who respond to a reminder to get scheduled for their visit.
  • Percentage of adults who are due for a preventive/ambulatory visit that the practice reaches out to in order to schedule them if they are not already scheduled.
    Suggested balancing measures:
  • One or more measures related to patient satisfaction.
  • One or more measures related to staff satisfaction.

Practices can also look at other metrics to understand the progress of specific improvement initiatives over time. This may include:

  • Progress on the Population Health Management Capabilities Assessment Tool (PhmCAT).
  • Progress towards foundational competencies listed in this implementation guide. For example: “Yes or no: Did your practice achieve the foundational competency “Screen for Chronic Conditions?”
  • Any other care gaps, clinical guidelines or measures your practice feels are important to prioritize.


Applying an equity lens

Your practice is likely achieving better outcomes with some patients than others. To understand these inequities, your practice should stratify your data based on race, ethnicity and language (REAL); sexual orientation and gender identity (SOGI); and other patient characteristics (e.g., social needs, etc.). See more in Key Activity 4: Use a Systematic Approach to Decrease Inequities within the Population of Focus. The ability to segment data in such a manner can lead to profound insights about structural challenges that drive some of the health outcomes. The Advancing Equity Through Data Quality and Reporting section of the PHMI Data Quality and Reporting Guide provides more guidance on this.


Putting it all together

We recommend that your practice record your measurement strategy in one place. This Measurement Strategy Tracker contains all the fields we believe are most useful; it can be customized to meet your practice’s needs.


6. Plan and hold regularly scheduled meetings of the implementation team.

Suggested team member(s) responsible: team lead or clinical coordinator or other individual tasked with coordinating the work of the team.

  • Hold time on team members' calendars for standing meetings. Consider biweekly (twice monthly) meetings to start with. The frequency, duration and focus of these meetings may change as you consider additional populations or subpopulations and additional sites or locations, and as the nature of the work changes.
  • Having a clinical perspective is an important aspect of this work. Consider models that minimize overall impact to patients’ ability to access care (i.e., having meetings before working hours or during lunch times; having providers attend crucial, rather than all, meetings; scheduling during providers’ administrative time).
  • Develop a system to efficiently report on all workstreams and track follow-up items. The Action Plan Template is one tool that can be used to focus your team around the foundational competencies and define responsibility for actions steps to be taken for each project your team has prioritized to work on.


7. Make adjustments based on data from the team’s measurement strategy and feedback loops.

Suggested team member(s) responsible: multidisciplinary team.

  • Review data and feedback at least monthly and adapt efforts as needed. Adaptation could include any or all of the following:
    • Amending the scope of work.
    • Modifying meetings or meeting structures.
    • Changing the team composition (adding or removing members).
    • Refining activities to better meet the needs of patients and staff, improve outcomes, or reduce inequities.
    • Modifying the measurement strategy and/or feedback loops to better understand what is (and is not) happening.
  • On an annual basis, the team’s charter and core membership should be reviewed. As the goals of the implementation team are met, the team could disband, meet less frequently (e.g., twice per year) or fold this meeting into a similar standing meeting that occurs separately.


Health Center Quality Measurement Systems Toolkit

The Health Alliance of Northern California created a summary crosswalk of measurement sets that provides an overview of alignment between measurement systems. It includes in-depth information on each Uniform Data System (UDS) or Quality Incentive Pool (QIP) clinical measure for diabetes care and hypertension, which is contained in a spreadsheet.
The document also shares suggested clinical interventions and community interventions for controlling diabetes and high blood pressure in rural northern California.

Evidence base for this activity

Pandhi N, Kraft S, Berkson S, Davis S, Kamnetz S, Koslov S, Trowbridge E, Caplan W. Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Serv Res. 2018 Nov 9;18(1):847. doi: 10.1186/s12913-018-3650-4. PMID: 30413205; PMCID: PMC6230270.