Chronic Disease Management/Transitional Care


The Chronic Disease Management/Transitional Care cohort is intended to drive events related to transformational healthcare by creating flow redesign, information sharing of best practices and lessons learned to make meaningful impact in terms of CQI centered outcomes.


Below is a table that lists all four of the change packages that we will provide throughout your participation in this cohort. Each topic will consist of a presentation followed by “homework” that cohort participants will take back to their facility/organization which should deepen their understanding of the topic. This “homework” will include performing PDCA cycles on specific AIM statements related to one of the participant’s 1115 waiver projects.

 Change Package No. 1Change Package No. 2Change Package No. 3Change Package No. 4
Title Improve Clinical Outcomes Decrease Burden of Chronic Disease Management Enhance Clinical Processes Use a Team Approach for Better Care Coordination
Topic One “Science of Improvement” - Data Collection Goal Driven Treatment Decrease Wait Time Care Coordination/Transitional Care
Topic Two Tracking Systems for a Proactive Rather than Reactive Approach Other Care Coordination Models Third Next Available Appointment Best Practice Models
Topic Three Patient Activation   Post-Hospitalization Visit  
Topic Four     Re-Route Non-Emergency ED Visits  
Topic Five     Open Access  

Package Number One: “Science of Improvement” - Data Collection

  • Topic One - Data Collection PowerPoint
  • Topic Two -Selection of Tracking System
  • Topic Three -Tracking Clinical Outcomes Using Patient Activation PowerPoint

Package Number Two: Decrease Burden of Chronic Disease

Package Number Three: Enhance Clinical Processes

  • Topic One - Decrease Wait Time
  • Topic Two - Third Next Available Appointment
  • Topic Three - Post-Hospitalization Visit
  • Topic Four - Reduced ED Utilization
  • Topic Five - Open Access

Package Number Four: Team Approach to Better Care Coordination

  • Topic One - Care Coordination/Transitional Care
  • Topic Two - Best Behavior Modification Model-Motivational Interviewing

Additional Tools/Resources