Increasing Chronic Disease Self-Management Initiative

Focus: Improving Cardiac and Vascular Health, Preventing and Managing Diabetes, Preventing End Stage Renal Disease (ESRD) 

Qsource encourages community coalitions to join us in this initiative to prevent the advancement of chronic diseases and improve outcomes for patients with chronic conditions. Through best practices, patient education and workflow improvement, we can help you identify chronic diseases earlier and improve your patients’ outcomes. 


Anticipated Impact

  • Increased patient satisfaction 
  • Increased use of best practices 
  • Reduced tobacco-use among patients 
  • Higher screening rates for chronic kidney disease 
  • Increased participation in diabetes self-management and diabetes prevention programs 
  • Increased patient engagement and motivation 

Who should get involved?

Identifying and addressing care concerns are essential in making improvement and involves incorporating the knowledge and experience from a variety of care providers and healthcare consumers, such as: 

  • Office Managers 
  • Front Office Staff 
  • Clinical Staff 
  • Healthcare Consumers 
  • Stakeholders 
  • ESRD Networks 


The assistance we provide is free. 

Reduced Time and Administrative Burden 

  • Assistance with developing improved workflows and process implementation 

Billing and Reimbursement Assistance 

  • Knowledge on how to improve clinical outcomes to increase monetary incentives 

Data and Benchmarking Assistance 

  • Data reports for Peer-to-Peer comparison 

Free Tools, Resources and Education 

  • On-demand learning online 
  • In-person technical assistance 
  • In-service training 
  • Best practice educational resources and tools 

Improved Patient Outcomes by: 

  • Increasing their health literacy and health status 
  • Becoming more adherent with lifestyle adjustments and behavioral changes 



Participation is voluntary. However, we ask that participants commit to the following: 

  • Adopt clinical best practices related to blood pressure management, aspirin prescribing, smoking cessation education, and cholesterol management. 
  • Incorporate screenings into annual wellness exams for high risk of diabetes complications and chronic kidney disease. 
  • Incorporate motivational and compassionate interviewing techniques to assess patients’ readiness and willingness to make lifestyle changes and promote positive self-care behaviors. 
  • Refer appropriate patients to diabetes self-management education (DSME) or National Diabetes Prevention Program classes, resources for diabetes self-management, and/ or managing of chronic kidney disease. 
  • Share EHR reports and data related to chronic disease measures. 
  • Collaborate with community coalition members, local businesses, other healthcare providers and healthcare consumers to get appropriate messaging out in the community related to chronic disease management.