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.
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In partnership with generous funders, patients, and health systems large and small, we specialize in co-designing and testing new, patient-centered models of care based on research evidence and best practices.
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We support their implementation in practice by designing approaches including ‘at-the-elbow’ practice facilitation, learning collaboratives, and other technical assistance.
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We translate what we learn along the way into public-domain assessments, toolkits, implementation guides, and other practical resources. Primary care teams everywhere can use these tools and resources to inform and accelerate their efforts to transform care. (Search our resource library.)
Featured projects in primary care transformation
Improving Chronic Illness Care
The Chronic Care Model: A proactive approach to population-based, patient-centered chronic illness care that's been adapted worldwide
Care Coordination Model
A roadmap for creating shared expectations among providers and community agencies to improve patient health and safety
Safety Net Medical Home Initiative
A framework to help safety net practices become high-performing patient-centered medical homes (PCMHs)
Learning from Effective Ambulatory Practices (LEAP)
Advancing team-based care with the Primary Care Team Guide
Delta Center for a Thriving Safety Net
Bringing essential partners together to advance policy, payment, and practice change in the safety net
Taking Action on Overuse
Improving value by reducing care that does more harm than good, with emphasis on the safety net
Recent news
Endowments 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