Improved Care for Chronic Conditions

What we do:

  • Assess the local health care delivery system and community resources for gaps in chronic care services
  • Work with stakeholders to plan specific quality initiatives to improve the delivery system and promote care integration
  • Monitor and evaluate changes on the system of care, practice behaviors and patient outcomes

Service Components:

  1. Identify and address policy, health practice, medical and non-medical (community and patient) service delivery gaps for persons diagnosed or at risk of developing a chronic health condition (diabetes, hypertension, lung disease, depression, etc.).
  2. Design care improvement initiatives at the system, practice, patient and community level using:
    1. Evidence based guidelines and best practice information
    2. Model practice and patient education, training and support
    3. Information technology
  3. Evaluate Improvement Initiatives with state-of-the-art qualitative and quantitative evaluation methods


  • Knowledge of the care delivery system, its strengths and weaknesses
  • Improved quality and access to care
  • More informed and pro-active providers and patients
  • Enhanced resources at each level of care - patients and families, practice, health system and community

Example Projects:

  • Blue Hill Chronic Care Improvement Plan
  • Aroostook County Chronic Care Technology Project


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 the World Health Organization (WHO).