​The delivery of care to people with chronic conditions requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.

In a well-designed delivery system, clinicians plan visits well in advance, based on the patient’s needs and self-management goals. During "group visits," patients see their clinician and meet with other patients with similar health problems. Nonphysician staff are cross-trained to provide care via standing orders.

Changes for Improvement

• Use Planned Interactions to Support Evidence-Based Care
• Ensure Regular Follow-Up by the Care Team
• Define Roles and Distribute Tasks Among Team Members