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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:



Collaborative Sponsorship Grants

Our Collaborative Sponsorship Grants Program awarded approximately $700,000 in grant funds.  Supported were organizations and/or initiatives in the following states:  Colorado, Wisconsin, Oregon, Maine, Vermont, Massachusetts, British Columbia, New Jersey, Minnesota, Arizona, and North Carolina.  


Targeted Research Grants

Our Targeted Research Grants Program provided a range of funding for peer-reviewed, applied research addressing critical questions about the organization and delivery of chronic illness care in health systems. The grants were used by researchers and practitioners in managed care organizations, group practices, academic institutions or research organizations; applicants from both the private and public sectors were welcomed.  The program awarded grants totaling approximately $6 million.



Integrating Self-Management Action Plans Into Primary Care for Patients With Coronary Heart Disease Risk Factors

Thomas Bodenheimer, M.D.
University of California at San Francisco

Study objective:
To: 1) assess whether the discussion of a healthy-behavior change action plan in primary care visits improves self-care behavior, self-efficacy and health status compared with patients receiving usual care; and 2) observe whether clinicians can incorporate action plans into primary care visits.


Assessing the Chronic Care Model in Small Primary Care Practices

Chris Feifer, Dr.P.H.

University of Southern California

Study objective:
Develop a self-administered instrument that measures adherence to the Chronic Care Model in small primary care practices.


Web-supported, Generic Planned Care for Office Practice

John H. Wasson, M.D.
Dartmouth Medical School

Study objective:
The Chronic Care Model (CCM) will improve care for a specific disease. However, in many small practices, the CCM does not easily generalize from one to many diseases. For this reason, experts in CCM have called for the evaluation of “Generic Planned Care”.


Testing the Criterion-Related Validity and Exploring the Clinical Utility of the Patient Activation Measure

Ron Stock, M.D.
PeaceHealth Oregon Region

Study objective:
To test the criterion-related validity of the recently developed Patient Activation Measure (PAM), and to conduct initial qualitative exploration of the perceived clinical utility of the Patient Activation Measure.


A Randomized Trial of Community-Based Case Management by Parent Mentors

Glenn Flores, M.D.
Medical College of Wisconsin

Study objective:
To determine whether Parent Mentors are more effective than traditional asthma care in reducing childhood asthma morbidity, costs, and use of services while increasing families' qualite of life, statisfaction, and self-efficacy.


Improving Use of Community Resources to Support Chronic Illness Self-Management

Elizabeth G. Eakin, M.P.H.
AMC Cancer Research Center

Study objective:
1) To partner with Clinica Campesina Family Health Services and local area community resource sites to adapt and translate a previously validated self-management/community resource intervention for use with a low-income, Spanish-speaking population; 2) to evaluate the self-management/community resource intervention in a RCT among low-income English and Spanish-speaking community health center patients with one or more chronic conditions; and 3) to evaluate the public health impact of the intervention on the RE-AIM dimensions of Reach, Efficacy, Adoption, Implementation and Maintenance.


Testing a Managed Care Approach, Group Visits, in Disadvantaged Patients with Type 2 Diabetes

Dennis Cope, M.D.
Medical University of South Carolina

Study objective:
1) To compare quality of care as measured by concordance with American Diabetes Association (ADA) guidelines including: vaccination rates for pneumonia and influenza, frequency of Hemoglobin A1c (HbA1c) and lipid profile measurements, screening for microalbuminuria, and appropriate use of angiotensin converting enzyme (ACE) inhibitors and aspirin; and 2) to compare health-related outcomes, including medical outcomes (e.g., HbA1c levels, lipid profiles), utilization patterns (e.g., outpatient visits, telephone contacts, ED visits) and patient satisfaction.


Project CHANGE: Chronic Care and Access Changes Need Good Evaluation

Leif Solberg, M.D.
HealthPartners Research Foundation

Study objective:
To evaluate the effect on the process and outcomes of care for adult patients with diabetes, heart disease or depression (as well as utilization and costs) as our 17 clinic medical group sequentially implements: 1) Advanced Access (same day access to primary care appointments) and 2) the Chronic Care Model.


A Randomized Clinical Trial of Collaborative Management in COPD

David Coultas
University of Florida

Study objective:
To determine the effectiveness of a nurse delivered collaborative management model in patients with COPD.


Drop-In Group Medical Appointments and Standard Assessment and Feedback for the Management of Pain in Primary Care

Tim Ahles, Ph.D.
Dartmouth College

Study objective:
1) To evaluate the feasibility of implementing the Dartmouth College Clinical Improvement System (DCCIS)/Drop-In Group Medical Appointments (DIGMA) intervention in primary care practices, and 2) to compare the outcomes of patients with chronic pain who receive DCCIS/DIGMS intervention compared to those who standard care.


Registry Development and Telephone Outreach to Asthma Patients: The Role of a Managed Medicaid Plan

Mark Doescher
University of Washington

Study objective:
To evaluate interventions aimed at improving asthma care in CHPW by creating an automated registry of asthma patients; testing whether quality of life and functional status improve, and whether avoidable utilization decreases through the Intervention; assessing the cost-effectiveness of this intervention; and improving collaboration among CHPW, community clinics and community groups.


Randomized Trial to Improve Transitions Between Health Care Settings for Persons with Chronic Illness

Eric Coleman
University of Colorado Health Sciences Center

Study objective:
To improve chronic illness care by: 1) enhancing information flow between health care settings, and 2) empowering patients and their caregivers to meet their health care needs during care transitions.


Adapting the Chronic Care Model to Treat Chronic Illness at the Salvation Army Free Clinic

Robert Stroebel, M.D.
Mayo Clinic

Study objective:
1) To organize the SAFC using the Chronic Care Model as a template to deliver effective chronic illness care. 2) To identify and follow a population of uninsured clients at increased risk for cardiovascular disease. 3) To document improved clinical outcomes in diabetes management, hypertension control and lipid management in this population of patients, and compare outcomes to community and national rates.


Evaluation of Community Readiness for Implementation of the Chronic Care Model

R. Adams Dudley
University of California, San Francisco

Study objective:
To assess whether selected communities are likely to achieve the system changes necessary to move towards fuller implementation of the Chronic Care Model.


Tele-video Nursing for Congestive Heart Failure Self-Management: A Controlled Trial

Patricia Patterson, R.N., Ph.D.
Oregon Health Sciences University School of Nursing

Study objective:
1) To estimate effect sizes of a self-management tele-video nursing intervention. 2) To estimate effect sizes when comparing intervention delivery modes. 3) To determine for whom intervention is most effective. 4) To evaluate Internet-based information for patient education. 5) To evaluate Internet-based inter-professional care.


Improving Self-care Among Rural Underserved Diabetics Using Web TV

John Schorling
University of Virginia

Study objective:
1)To help patients improve their diabetes self-care activities. 2) To capture participants¹ daily self-monitoring data in a centralized database for provider review and feedback. 3) To promote patient activation and empowerment and improve patient-provider interactions.


Improving CHF Outcomes Through Automated Clinical Data Acquisition and Targeted Telephone Outreach

Doug las Roblin, M.P.H.
Kaiser Permanente-Georgia

Study objective:
To improve clinical outcomes and quality of life of patients with CHF through 1) incorporating telephone-based acquisition of data critical to management of CHF, and 2) directing nurse case manager advice to patients most likely to benefit from intensified intervention.


Self-Management Support in a Web-Based Medical Record

Harold Goldberg
University of Washington

Study objective:
To integrate a computerized diabetes self-management support module & clinical data at the time of the physician/patient interaction within an electronic medical record based on the World Wide Web, and to conduct a comparison of the impact of that module based on motivational interviewing techniques, vs. the usual care of non-interactive text guidelines available via hyperlinks to external sites.


Improving Self-Management and Healthy Lifestyles in Medicaid & Dual Enrolled Medicare People with Diabetes

Gayle Reiber, M.P.H.
University of Washington, VA Puget Sound Health System

Study objective:
To determine if a diabetes-enhanced version of the Health Enhancement Program will result in improved glycated hemoglobin values and reduced health care costs after a one-year intervention program.