Diabetes High Blood Pressure Quality Improvement Team Based Care

Fact Sheets

Success Stories

What's Working in Chronic Disease Prevention and Control Database

The National Association of Chronic Disease Directors' What's Working database houses state and local successes and initiatives to help state and territorial health departments, partners, and decision makers learn more about What's Working in Chronic Disease Prevention and Control.

Contribute your work today! (Users must login to the NACDD website to submit an entry.)

Health Information Technology Million Hearts® Policy
  • CDC Health Policy Series from the CDC Office of the Associate Director for Policy
  • Overview of Community Integration Structures and Emerging Innovations in Financing
    This policy brief explores opportunities to establish effective, more sustainable community-focused delivery and payment models to improve population health.
    • Evolving community-level population health delivery models
    • Key functions, opportunities, and challenges of a community integrator
    • Concept of a balanced portfolio as a crucial component in developing a sustainable financial model
    • Emerging financing vehicles that could be used for specific population health interventions
  • Public Health Departments and Accountable Care Organizations (ACOs)
    This policy brief focuses on the interface of public health departments and ACOs and highlights opportunities for enhanced collaboration between the two entities.
    • Public health might act as a convener of ACO partnerships
    • Public health can provide analysis of population health data, surveillance, needs assessment, and outcome evaluation
    • Public health can be a direct service delivery partner by providing primary care services or wrap around services such as care coordination
Quality Improvement
Making Connections

Measure Up/Pressure Down® is a three-year national campaign created by the American Medical Group Foundation, designed to engage stakeholders in improving blood pressure control and achieving lasting improvements that lead the way to greater health, productivity, and cost savings.

Quality Improvement Organization
Connect with your local CMS Quality Improvement Organization (QIO)

CMS Innovation Center
Learn more about your states participation in various health care initiatives by visiting the Center for Medicare & Medicaid Services Innovation Center. There you can search by state for "Where Innovation is Happening"

Model for Improvement

Quality Improvement Principles

  • Listen to customers (patients)
  • Tap into the people within the system
  • Understand processes and interactions within the system
  • Measure to learn and understand variation
  • Test on a small scale to test change ideas

Model for Improvement & Plan Do Study Act
The Model for Improvement is a framework used by many to guide improvement work. The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement.

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change - by planning it, trying it, observing the results, and acting on what is learned.

To learn more about MFI & PDSA visit: Institute for Healthcare Improvement

Example using the Model for Improvement and PDSA for improving the detection of high blood pressure

Practice Facilitation

Practice facilitation, sometimes also referred to as quality improvement coaching, is an approach to supporting improvement in primary care practices that focuses on building organizational capacity for continuous improvement (Knox, 2010).

Practice facilitators (also known as practice coaches, QI coaches, and practice enhancement assistants) are specially trained individuals who work with primary care practices "to make meaningful changes designed to improve patients' outcomes. They help physicians and quality improvement teams develop the skills they need to adapt clinical evidence to the specific circumstance of their practice environment" (DeWalt, et al., 2010).

Practice facilitators can play a key role in helping practices to implement team-based care by assisting with the set-up of care teams, redesigning workflows, clarifying each team member's role, and establishing more effective means of communication to strengthen team approaches to care. The Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers provides exercises that practice facilitators can use to increase practice staffs' understanding of how using a team-based model to spread workloads and shift responsibilities benefits both care team members and patients.

For more information on how to help primary care practices use team-based care to improve the delivery of care, see Module 19 of The Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers. You can download a PDF copy of the entire handbook free of charge at the PCPF Resources page of AHRQ's PCMH Resource Center

Self-Measured Blood Pressure Monitoring Team Based Care
Community Health Worker

Guide for States Implementing Community Health Worker Strategies
This technical assistance guide summarizes the successful work of organizations as it relates to Domains 3 and 4 (Health Systems Interventions and Community-Clinical Linkages, respectively) of CDC's State Public Health Actions Program (CDC-RFA-DP13-1305). It also offers insights for states that are implementing Community Health Worker (CHW) strategies


The following are trainings and webinars related to 1305, Domain 3 cardiovascular and diabetes strategies and performance measures. Content to this section will be updated periodically.

Health Information Technology

EHRs and Improving Blood Pressure
American Medical Group Association
Measure Up / Pressure Down: Improving Blood Pressure Control in Washington, DC July 2015
For Audio and Slides, Click Here
For Slides Only, Click Here

Million Hearts
Quality Improvement
Self-Measured Blood Pressure Monitoring

Information to Come

Team-Based Care

Information to Come