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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:


Practice Change

The Chronic Care Model describes the necessary components for a delivery system that encourages and sustains productive interactions between patients and providers.  Since 1998, ICIC has interacted with hundreds of practice systems, large and small, as they worked to implement the Model.  We have learned that the hard work of clinical practice change requires more than just good intentions and a goal.  

We’ve eassembled five categories of practice change tools and instruments to help in the challenging but critical work of delivering CCM-based care.

Assessing your practice
Health care organizations require practical assessment tools to guide quality improvement efforts and evaluate changes in chronic illness care. In response to this need, the ICIC staff developed the Assessment of Chronic Illness Care (ACIC, Bonomi et al., 2002), the Patient Assessment of Chronic Illness Care (PACIC, The MacColl Institute, 2004), and the Patient-centered Medical Home Assessment (PCMH-A) surveys.

Shifting to team-based care
The LEAP Team Guide presents practical advice, case studies, and tools from these exemplary primary care practices that have markedly improved care, efficiency, and job satisfaction by transforming to a team-based approach.

Tackling medical overuse
The Chronic Care Model was developed to help health care systems address gaps or missed opportunities to provide effective services to those in most need of care.  In 2016 we developed the Taking Action on Overuse framework to address the flip side: overuse.  In both models, the aim is the right care at the right time to ensure healthier patients, and more satisfied providers and staff.

Using practice coaches
A growing body of evidence shows that practice facilitation, or coaching, can mean the difference between a primary care team’s success or failure in becoming a patient-centered medical home. 

Integrating self-management support
Enabling patients to make good choices and sustain healthy behaviors requires a collaborative relationship:  a new health partnership between health care providers and teams, and patients and their families.