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Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:


Change Package

Practices wanting to improve the coordination of their care should consider making changes to practice systems and processes consistent with four elements—accountability, relationships and agreements, patient support, and connectivity.


These four areas represent high-level “change concepts,” which the Institute for Healthcare Improvement defines as “general ideas…that can be adapted to make specific changes that lead to improvement in many processes and clinical areas”.  In aggregate  they describe the “change package” for better care coordination.  But, to be useful, suggested changes to a practice must be more specific.  The following table identifies the six key changes in the Care Coordination Model, as they apply to each change concept, and the specific activities involved in making the key change.  Related materials that might be of help are presented in "Tools & Resources".