Populations of Focus

Adults Living with Chronic Conditions Guide

Version 3 – June 2026

Suggested Citations and Acknowledgements


Recommended citation:Burgess K, Brettler J, Roy B, Deane M, Baker L, Howard P, Donald F, Rachman F, Esmond W. Adults Living with Chronic Conditions Implementation Guide. In: Coleman K, Mital M, editors. Population Health Management Initiative Populations of Focus Implementation Guide Series. 1st ed. Oakland, CA: Kaiser Permanente; 2024.

Acknowledgments: We gratefully acknowledge the contributions of the many staff and representatives of the Institute for Healthcare Improvement (IHI), AllianceChicago, Center for Care Innovations (CCI), JSI Inc and the Center for Excellence in Primary Care at University of California, San Francisco along with Pyramid Communications and Kaiser Permanente’s Population Health Management Initiative (PHMI) team for crafting this work.

In addition, we are grateful for the partnership of the Department of Health Care Services (DHCS), Community Health Center partners in PHMI, representatives from the California Primary Care Association and the Regional Associations of California (RAC) along with the many other academic, health plan and consulting partners who shared their expertise and insights freely as we collaboratively designed the initiative and created these guides.

Special thanks to the individual reviewers of this first edition of the Populations of Focus Implementation Guide Series who significantly strengthened this work, including: Jeff Norris, Laura Miller, David Tian, Karen Mark, Palav Babaria (DHCS); Jennifer Sayles (Pop Health Learning Center); Roger Chaufournier, Christine St. Andre (IHI); Kathleen Figoni, Angela Sherwin (CCI).