The Adults Living With Chronic Conditions Guide provides step-by-step guidance to help Community Health Centers and other primary care practices improve person-centered, population-based care for adults living with chronic conditions. It focuses on controlling high blood pressure (hypertension), comprehensive diabetes care, and access to preventive and ambulatory services through practical strategies that support clinical care, quality improvement, equity, and sustainable practice change.
The guide includes foundational, going deeper, and on the horizon activities addressing multidisciplinary care teams, clinical practice guidelines, care gap reports and registries, patient outreach, standing orders, pre-visit planning, chronic condition screening, medication management, patient self-monitoring and self-care, behavioral health integration, health-related social needs screening, care coordination, community partnerships, referral pathways, Food is Medicine, and remote patient monitoring.
Each activity includes guidance for planning, testing, implementation, technology considerations, measurement, and ongoing workflow improvement.