Building Community-based Chronic Disease Interventions

Updated: June 10, 2016

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This handbook describes how to assemble regional collaboratives of primary care practices, specialists, hospitals, and others to address specific disease conditions. The manual covers identifying a chronic condition to focus on, designing the project, recruiting participating providers, establishing governance, choosing and tracking goals and measures, implementing, and sustaining changes.

PCDC developed this handbook in cooperation with the Fort Drum Regional Health Planning Organization. We developed it through experiences and lessons learned on FDRHPO’s North Country Health Information Partnership and other projects. This handbook is derived from one available to be downloaded directly from FDRHPO.