Services

Research and Evaluation

Chronic Care Planning and Services Improvement

The Public Health Resource Group (PHRG), headquartered in Portland, Maine, USA consults with healthcare organizations, governments and associations to plan and implement evidence-based service delivery improvements for practices, health systems, communities and countries. This work is grounded in 18 years of planning in over 80 different engagements in the US and abroad. To accomplish this work PHRG developed its Chronic Care Improvement Module comprised of the Chronic Care Services Improvement Roadmap and accompanying Rapid Assessment Tools and Patient Self-management Improvement Paradigm. PHRG’s Chronic Care Improvement Module is designed to identify policy, practice change, clinical, and non-clinical (community and patient level) service gaps in the care of persons diagnosed or at risk of developing chronic disease. This module provides communities, health systems and/or hospitals with a systematic process to plan and implement disease prevention and management programs that improve patient health status, self-management skills, office and system workflow, as well as patient and provider satisfaction. The module also provides the information needed for participation in pay for performance and other current financial initiatives for improvement.

The Chronic Care Services Improvement Roadmap depicts the assessment, implementation and evaluation phases for chronic care improvement and comprises rapid assessment tools developed (to date) for assessment, implementation and evaluation of chronic care improvement projects. PHRG has successfully demonstrated the use of the roadmap and rapid assessment tools over the past several years to plan, implement and/or evaluate medical practice, system and patient self management innovations. These projects have addressed the needs of patients at risk of and diagnosed with one or more chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), diabetes, depression, heart disease, hypertension, hyperlipidemia, smoking treatment addiction and end of life care. Blue Hill Memorial Hospital and Central Kenai Peninsula Hospital Service Area Chronic Care Assessment and Planning Executive Summary Reports summarize two recent examples of chronic care planning and information technology projects we have participated in over the past two years.

These assessment and planning tools and processes bring clarity and understanding to the complex issues of improving care for the prevention and treatment of chronic conditions. The tools and expertise at PHRG can help you strengthen the chronic care delivery system in your community, health system or health practice through evidence based practice, information technology, policy reforms and/or improved patient self-management education and support.

The framework for the Chronic Care Services Improvement Roadmap and rapid assessment tools is the Innovative Care for Chronic Conditions Framework (ICCC) and building blocks developed by World Health Organization (WHO). The ICCC framework and building blocks, an expansion of the Chronic Care Model developed by Dr. Ed Wagner and his colleagues at the MacColl Institute, provides a realistic paradigm for understanding the drivers of patient and population health status for persons with chronic medical conditions. Each component of the framework—the policy environment, the health system, the community, patients and their families—are essential "building blocks" that can be used to help decision-makers determine gaps to be addressed in the health care system that advance capacity to manage long-term health.

For more information on how PHRG’s planning expertise can help you in this area please contact Dr. Ronald Deprez by phone (207-761-7093) or by Email

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