Adults Living with Chronic Conditions Guide

It is estimated that six in 10 U.S. adults are living with a chronic disease, and chronic diseases are the leading cause of death and disability in the United States^[1]. The impact of chronic conditions and the rates of complications are higher in historically marginalized populations^[2]. One of the most effective ways to manage chronic diseases and reduce health inequities is by applying a systematic, team-based care approach to wellness visits for chronic disease screening and to subsequent scheduled visits for management. Adopting standard procedures to identify and manage chronic conditions allows practices to provide high-quality, person-centered, culturally responsive care to patients, foster efficiency, and reduce clinician and staff burden. Systematic care that incorporates a person-centered approach to managing chronic conditions improves equity in care and patient outcomes by:

• Improving health and well-being among all patient populations.
• Recognizing and reducing potential barriers to care.
• Reducing burnout among clinicians and staff.

The work to ensure that patients have access to high-quality, person-centered diabetes and hypertension care is a continuous effort. This document uses existing evidence, bright spots and examples from the field to offer practical guidance on improving the effectiveness of your diabetes and hypertension management protocols while ensuring patient access to preventive care, keeping in mind that it will be adapted to your practice’s unique context.

Key activities in this guide are organized into three categories:

• Foundational activities: Activities that all practices should implement as part of the activities to support diabetes care, controlling high blood pressure, and adults’ access to preventive and ambulatory health services.  
• Going deeper activities: More advanced activities that build off of the foundational activities and that help ensure your practice can achieve equitable improvement in your patients’ management of chronic diseases, including diabetes and hypertension. 
• On the horizon activities: Additional activities, including ideas worthy of testing that include the latest ideas and thinking on management of chronic diseases, including diabetes and hypertension. 

Where to Start: While we recommend following the sequence of the key activities in this guide, the activities can be used individually or adapted to fit your practice’s priorities.

Trying it Out then Making it Habit: For each activity, we provide guidance on how to plan, try, and implement the activity along with links to other resources, technology considerations and examples. Consider trying different versions of the action steps and roles with a smaller group before fully implementing at your practice.

Maintaining Progress: Ongoing review and continual improvement are important for your practice to maintain your progress in population health management and to help you stay nimble in adapting to changing patient demographics, new clinical best practices, new payment policies, workforce changes and other changes at your practice. For many activities, we also provide tips for periodically reviewing and making improvements to key workflows after initially implementing the change.

If you implement the Foundational Activities in this guide, your practice should be able to achieve the following objectives:

1. Engage patients served by your practice to validate any of your proposed process improvements and to propose alternative methods to improve quality in your focus area.
2. Analyze core quality measures to identify inequities and opportunities for improving A1c control and blood pressure among attributed patients.
3. Implement chronic care management activities.
4. Create an outreach protocol to reach and engage all attributed patients due for care.
5. Integrate behavioral health follow-up services as needed (e.g., for positive depression screens).
6. Create a health-related social needs screening process that informs patients’ treatment plans.
7. Assess current capabilities and develop a plan for ongoing improvement in data utilization, care team workflows and efficiency that includes sustainable health information technology (HIT) strategies and continuous staff training on technology.

This guide also includes sections on measurement, equity, social health, behavioral health integration and an appendix including helpful tools and resources. We have included information about California Medi-Cal covered benefits and services that were up-to-date at the time of publishing, but benefits and billing guidance change over time. Nothing in this guide should be considered formal guidance, and anyone using this guide should check with the appropriate authorities on benefits and billing guidance.

This is a living document and will change based on continued learning on this topic and may include additional activities, examples, resources and sections in the future.

Additional Information can be found in Getting Started: Introduction to the PHMI Implementation Guides, and Aligning PHM Principles with Community Health Clinic Strategic Planning.

Working to improve the health of a population leverages everyone in a practice. Critical roles needed to engage in the work outlined in this guide and support practice change include:

• Quality improvement (QI) leadership, like a QI director, or additional team leads (i.e., clinical, front office, etc.) to support cultural changes.
• Coaches or practice facilitators who are partnered with teams to help identify areas for improvement and support change through change management strategies.

PHMI’s approach emphasizes four foundational areas for PHM: a reimagined care team, empanelment, the business case, and data quality and reporting (DQ&R). These areas provide the foundation for the sustainable delivery of person-centered, population-based care and improving outcomes for a population of focus; see Building the Foundations for Population Health Management: Talking Points for Engagement for a concise overview and talking points for why these areas are important.

In addition, practices can reference specific Building the Foundations key activities to go deeper into specific challenges related to advancing equity, social health, behavioral health integration, and access and outreach for their population of focus:

Equity

• Business Case Guide: Advancing Equity Through Your Business Case
• Empanelment Guide: Advancing Equity Through Empanelment
• Data Quality and Report Guide: Advancing Equity Through Data Quality and Reporting
• Care Teams and Access Guide: Advancing Equity Through Care Teams and Workforce
• In this guide: Key Activity 4: Use a Systematic Approach to Decrease Inequities Within the Population of Focus, and Key Activity 21: Strengthen a Culture of Equity

Social Health

• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure
• In this guide: Key Activity 14: Use Social Needs Screening to Inform Patient Treatment Plans

Behavioral Health

• People with Behavioral Health Conditions Guide
• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure and Key Activity 2: Identify gaps in staffing and decide how to address them
• In this guide: Key Activity 12: Incorporate Behavioral Health Integration to Support Chronic Conditions Self-Management and Address Comorbid Behavioral Health Conditions

Access and Outreach

• Empanelment Guide: Going Deeper: Connecting Empanelment with Patient-Centered Access
• Care Teams and Workforce Guide: Key Activity 2: Identify Gaps in Staffing and Decide How to Address Them
• In this guide: Key Activity 6: Proactively Reach Out to Patients Due for Care