Primary Care Transformation

Transforming primary care to better serve patients has been at the heart of our work since Dr. Ed Wagner and his team developed the widely adopted Chronic Care Model in the mid-1990s.

Primary Care Transformation

Transforming care to better serve patients is at the heart of what we do.

Transforming care with a practical, patient-centered approach since the 1990s

Transforming primary care to better serve patients has been at the heart of our work since Dr. Ed Wagner and team developed the widely adopted Chronic Care Model in the mid-1990s. The Chronic Care Model reshaped how care teams and patients worldwide navigate chronic illness care. With a patient-centered, evidence-based approach focused on population health, the Chronic Care Model became the new standard in caring for chronic conditions — and the inspiration for our future work.

Since then our team has leveraged this foundational experience to develop dozens of practical tools to support care transformation. 

Featured projects in primary care transformation

 

Improving Chronic Illness CareModel_Chronic_Care_Featured.jpg

The Chronic Care Model: A proactive approach to population-based, patient-centered chronic illness care that's been adapted worldwide

 

Care Coordination Modelcare-coordination-model-image.jpg

A roadmap for creating shared expectations among providers and community agencies to improve patient health and safety

Safety Net snmhi-website.pngMedical Home Initiative

A framework to help safety net practices become high-performing patient-centered medical homes (PCMHs)

LPrimary-Care-team_2col.jpgearning from Effective Ambulatory Practices (LEAP)

Advancing team-based care with the Primary Care Team Guide

Delta Center for a Thriving Safety Netjsi-delta-center-convening-2024.JPG

Bringing essential partners together to advance policy, payment, and practice change in the safety net

Taking Action on OveruseValue-Champions-Clinicians_Taking-Action-On-Overuse_op2_2col.jpg

Improving value by reducing care that does more harm than good, with emphasis on the safety net
Transforming care since 1992

From our roots in transforming chronic illness care to our more recent projects to advance high-value care, the tools we’ve developed have evolved to focus on some of health care’s emerging challenges.  Learn more:

Recent news

KPWA-Residents_STFM-Poster-2024_Sized.jpgEndowments support equity in hypertension care

August 16, 2024


Partnering to advance health equity in the safety net

May 3, 2024


What works to meet complex needs in diabetes care?

February 12, 2024


Rapid Engagement promotes person-centered access for Oregon Behavioral Health

July 25, 2023


Why we need practice facilitators now more than ever

October 3, 2022