Delivering Team-Based Chronic Care Management: Overcoming the Barriers

Updated: January 9, 2017

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This is a report on the Integrated Care Planning Initiative, a PCDC-led project begun in 2014 funded by the Altman Foundation and The Morton K. and Jane Blaustein Foundation to better address and overcome the challenges related to implementing and delivering chronic care management (CCM) in a primary care setting. The initiative created a learning community where organizations providing both primary care and care management for Medicaid patients in New York State worked on developing solutions for their specific challenges, shared best practices, and learned from one another.

This report provides discussion and key findings from the project. It also includes organizational and policy level recommendations to support and inform stakeholders looking to implement effective team-based CCM. The Appendices contain a PCDC-developed roadmap, examples of workflows and tools developed by participants, findings from a literature review, and case studies of successful large scale care management programs across the country.