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The Chronic Care Initiative

CHRONIC CARE INITIATIVE

The Chronic Care Initiative, originally operated by the Pa. Dept. of Health, enrolled more than 150 primary care practices in its multiple regional collaboratives.

The PAFP, contracted with the Chronic Care Initiative, received grant funds from the Pa. Dept. of Health to provide data management for all practices and interventional coaching services for low-performing practices.

Participating practices achieved excellent results, including: 
  • Decrease the percent of patients with DM in participating practices who have an A1C measure of greater than 9% from 33% to 20% (target: <5 %). 
  • Increase the percent of patients with DM in participating practices whose BP is documented in the past year < than 130/80 mm Hg from 40% to 49% (target: >70%). 
  • Increase the percent of patients with DM in participating practices with LDL < 100 mg/dl from 38% to 50% (target: >70%).
  • Increase the percent of patients with DM in participating practices who have a self-management goal documented within the past 12 months from 33% to 62% (target: >90%).

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