Diabetes Example:

Aim: Redesign the organization's systems to provide comprehensive care to our diabetic patients. This will be accomplished through patient self-management education and follow-up, decision support, delivery systems, information systems, community relationships, and leadership.

Team:

Clinical/technical expert: Medical Assistant

Day-to-day Leader: RN Patient Care Director

Other team members: Dental Director, Chief Executive Officer

Asthma Example:

Aim: Implement components of the Chronic Care Model to show a 40% increase in symptom-free days and 50% decrease in ER visits. 90% of patients with persistent asthma will be treated with antiinflammatory meds, and at least 90% of patients will have a written asthma action plan.

Team:

Team Leader: Clinical Services Director

Clinical/technical expert: Certified Family Nurse Practictioner

Day-to-day leader (key contact): Asthma Nursing Coordinator

Depression Example:

Aim: Redesign the clinical process to improve the care of depression via identification, structured assessment, and access to continuing treatment options. This will be achieved by implementing all components of the Chronic Care Model so that 60% of patients with a diagnosis of depression will have a PHQ score of <5 at their last visit.

Team:

Team leader/physician champion: Medical Director

Clinical/technical expert: Clinic Director

Day-to-day leader: Quality Coordinator

Other team members: Chief Executive Officer, Case Manager, Data Coordinator, Office Manager