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Introduction
Putting the Key Activities in Context
Foundational Key Activities
1. Convene a Multidisciplinary Implementation Team for Chronic Care Management
2. Update or Implement Clinical Practice Guidelines
3. Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care
4. Use a Systematic Approach to Decrease Inequities Within the Population of Focus
5. Expand Person-Centered Access to Care for Chronic Conditions
6. Proactively Reach Out to Patients Due for Care
7. Develop and Implement Standing Orders
8. Develop or Refine and Implement a Pre-Visit Planning Process
9. Screen for Chronic Conditions
10. Manage Medication Therapies
11. Foster Patients’ Ability to Self-Monitor Their Blood Pressure and/or Blood Glucose at Home
12. Incorporate Behavioral Health Integration to Support Chronic Conditions Self-Management and Address Comorbid Behavioral Health Conditions
13. Support Patient Self-Care
14. Use Social Needs Screening to Inform Patient Treatment Plans
15. Coordinate Care
Going Deeper Key Activities
16. Provide Group Visits for Chronic Care Management
17. Strengthen Community Partnerships
18. Provide Care Management
19. Continue to Develop Referral Relationships and Pathways
20. Addressing Food is Medicine Needs of Individuals with Chronic Conditions
21. Strengthen a Culture of Equity
On the Horizon Key Activities
22. Develop System to Provide Remote Monitoring
Appendices
Appendix A: Sample Idealized System Diagram
Appendix B: Theory of Change
Appendix C: Developing a Robust Measurement Strategy
Appendix D: Other Sources Reviewed in the Writing of This Guide
Appendix E: Guidance on Technological Interventions
Suggested Citations and Acknowledgements
Populations of Focus
Adults Living with Chronic Conditions Guide
Version 3 – June 2026
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APPENDIX D:
Other Sources Reviewed in the Writing of This Guide
ADA’s Standards of Care in Diabetes.
View resource
USPSTF’s Prediabetes and Type 2 Diabetes in Children and Adolescents: Screening
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USPSTF’s Gestational Diabetes: Screening.
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USPSTF’s Prediabetes and Type 2 Diabetes: Screening.
View resource
USPSTF’s Hypertension in Adults: Screening.
View resource
USPSTF’s Hypertensive Disorders of Pregnancy: Screening.
View resource
Centers for Disease Control and Prevention’s: Your Diabetes Care Schedule.
View resource
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