Chronic Conditions - Key Activity 2


Update or Implement Clinical Practice Guidelines


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.


Clinical practice guidelines are established standards of care that provide evidence-based recommendations for the diagnosis, treatment and management of various health conditions. They are established through a systematic review of evidence-based practice from a variety of sources, often from experts in the field. By following these guidelines, healthcare clinicians can ensure that patients receive high-quality care that is supported by current evidence-based practice. Clinical practice guidelines also help standardize care across different healthcare settings, which can improve patient outcomes, reduce healthcare costs and improve health equity.[1] Having guidelines is especially important for hypertension and diabetes management due to the complexity of ongoing management of these conditions.

Clinical practice guideline implementation is important because:

  • They ensure that there are minimum standards of care within the practice.
  • Care inequities can be reduced by providing universal standards.
  • Guidelines allow for the development of other standard processes (i.e., standing orders), which help to reduce clinician burden. See Key Activity 9: Develop and Implement Standing Orders for more information.
  • They facilitate a team-based model of care, which can be streamlined with standardized practices.

Clinical practice guidelines help promote equity by providing evidence-based recommendations for effective management of diabetes and hypertension. This ensures that care is standardized across the practice. While implementing clinical practice guidelines does not directly address social needs, enabling supportive care team members other than the primary care clinician to initiate care provides the opportunity to assess and to meet patients’ social needs.

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). Reports should have the capacity to filter by clinician, location and care team (where applicable).
Access to outside data may be a consideration or requirement (e.g., California Immunization Registry/immunization registry data and data from other practices) as services received outside the health center may be an important part of screening and follow-up. Ideally, this is accomplished by real-time data exchange, but where not possible, it may require manual entry. This may need to include not only the EHR but care coordination/population health management applications or freestanding referral registries. While claims data may be helpful in this regard, lag time may impact its usefulness. Patient-facing applications should be strongly considered to promote patient activation by helping ensure that patients are informed and appreciative of the nature and importance of recommended care. See Key Activity 24: Develop System to Provide Remote Monitoring for additional information.

Action steps and roles

1. Review the current, most up-to-date clinical guidelines and update appropriately.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement lead.
See the section titled Clinical Practice Guidelines earlier in this guide. Ensure your practice is using the latest guidelines.

In addition to those guidelines, you can review the following resources:

PHMI Clinical Practice Guidelines.


2. Develop standard methods of updating clinic staff on changes within key guidelines.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement lead.
These updates could be provided during a set meeting time, via email communication, via video update, etc.

3. Ensure access to evidence-based clinical decision support systems.

Suggested team member(s) responsible: administration and medical director (or equivalent).
Clinical decision support provides staff with information that is relevant to the care situation at appropriate times to enhance health and healthcare.[2] This provides easy access to support such as clinical practice guidelines and medication alerts. These are sometimes integrated into the Electronic Health Record (EHR).

4. Regularly evaluate and support the infrastructure of patient care teams to ensure adequate redundancy and staffing.

Suggested team member(s) responsible: administration, medical director (or equivalent) and nursing director (or equivalent).

Part of developing the infrastructure for care teams to properly integrate clinical guidelines is providing adequate equipment for staff. This includes providing validated, automated monitors and adequate supplies of all blood pressure cuff sizes to each care team. Point-of-care A1c tests are another aspect of infrastructure that can be considered. Staff should also be trained upon hire, and annually thereafter, on proper blood pressure measurement procedures. This ensures that all staff are trained and available to utilize equipment. Staff should also be trained on other aspects of workflows, such as rooming, pre-visit planning (PVP), huddles, etc., in order to ensure that care does not suffer if a crucial staff member is unavailable on a certain day.

Additionally, practices should regularly evaluate clinic workflows and clinician panels to ensure that the number of staff that are allocated to each area is adequate. See the PHMI Empanelment Guide and Care Teams & Workforce Guide for more information.

5. Develop guidelines that reflect a spectrum of treatment needs.

Suggested team member(s) responsible: administration, medical director (or equivalent) and nursing director (or equivalent).

Guidelines should provide evidence-based recommendations for intensification of treatment, which emphasizes performance feedback. This can be for initiatives such as following up on lab results or utilizing guidelines for medication measures. Additionally, clinicians should be educated regarding how to best address common side effects and lab abnormalities.

Implementation tips

Facilitate opportunities to share/collaborate with behavioral health colleagues about the clinical practice guidelines for chronic diseases management. Much of chronic disease management requires patients to engage in behavior change. Behavioral health colleagues bring skills and strategies that best support patients in making and sustaining the changes necessary to initiate and maintain behavior change


  1. American Diabetes Association. Erratum: standards of care in diabetes—2023 abridged for Primary Care clinicians. Clin diabetes 2023;41:4–31. Standard of Care in Diabetes--2023. 2022 Dec 12;41(2):328–328. doi:10.2337/cd23-as01 
  2. Clinical decision support [Internet]. 2018 [cited 2024 Jan 8]. Available from: