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The Institute for Healthcare Improvement and Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation, have both developed and adapted tools to help organizations accelerate their work to improve the care for patients with chronic conditions. In addition, many organizations have developed tools in the course of their improvement efforts — successful flowcharts, forms, instructions and guidelines for implementing key changes — and are making them available on IHI.org for others to use or adapt in their own organizations. We invite you to submit tools you have found useful!
The tools below are grouped according to the key areas of the Chronic Care Model where changes must be made to improve care for people with chronic conditions.
For more information also see specific Diabetes tools and Asthma tools.
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Delivery System Design Tools
Organization of Health Care Tools
Self-Management Tools
Self-Management/Consumer Involvement
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Delivery System Design Tools
This step-by-step manual was developed to help health care organizations improve chronic care for their patients with diabetes, asthma, depression, and other chronic diseases; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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The Continuing Care Clinic Handbook is a step-by-step guide to establishing more efficient patient visits using periodic half-day visits to your clinic to meet multiple patient needs; developed by Improving Chronic Illness Care (Seattle, Washington, USA)
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Organization of Health Care Tools
A simple, comprehensive survey tool to assess your organization's current levels of care with respect to the six components of the Chronic Care Model (community resources, health organization, self-management support, delivery system design, decision support, and clinical information systems); developed by Improving Chronic Illness Care (Seattle, Washington, USA)
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A 57-minute presentation walking through the Chronic Care Model as presented by Dr. Ed Wagner, Director of the Improving Chronic Illness Care national program; developed by Improving Chronic Illness Care (Seattle, Washington, USA)
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Touchpoint Health Plan (Appleton, Wisconsin, USA) uses this benchmarking tool to compare its results for preventive care, diabetes, asthma, depression, and more with other organizations in its network and with national averages.
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Self-Management Tools
This visual aid, based on principles of health literacy, consists of a color thermometer and recognizable faces from smiling to frowning to indicate the patient's current blood pressure. It provides an easy way for patients to understand their current measurement and goals for reducing their hypertension; developed by CareSouth Carolina (Hartsville, South Carolina, USA).
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The Patient Planning Worksheet is a form to help people with chronic illnesses develop a personal plan to learn a new behavior, such as starting a program to increase their physical activity; developed by Improving Chronic Illness Care (Seattle, Washington, USA)
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A self-management support tool used for long-term planned care; developed by Whatcom County Pursuing Perfection Project (Bellingham, Washington, USA)
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Self-Management/Consumer Involvement
The Group Visit Starter Kit will provide you with step-by-step instructions on how to begin running group visits with your patients; developed by Improving Chronic Illness Care (Seattle, Washington, USA)
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Health Disparities Collaborative Training Manual for Chronic Conditions
This step-by-step manual was developed to help health care organizations improve chronic care for their patients with diabetes, asthma, depression, and other chronic diseases.
Workspace on IHI.org
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