Chronic Care Referral Program

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Chronic Care Referral Program

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Programs and Services

Chronic Care Referral Program

Transforming Chronic Care

The Transforming Chronic Care Program (TCC) is focused on improving clinical outcomes for patients with chronic health problems. It is based on the Chronic Care Model (CCM) first defined by Dr. Ed Wagner from the Group Health Cooperative of Puget Sound. This model is based on the assumption that improvement in care requires an approach that accounts for the patient, the provider, and the system level interventions.

We serve patients who have chronic conditions and our primary focus is:

Chronic care management continues to evolve, but it is clear that what matters most is the patient's own ability to manage his or her own disease. Successful interventions in the care of chronic diseases are composed of complex sets of actions that address psychosocial and lifestyle issues as well as physical problems. This program empowers patients to self manage their illnesses and transform health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.

The John Muir Physician Network has developed two Programs to improve the quality of our Chronic Care:

I am a physician and would like to refer a patient to this program.

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Chronic Care Referral Program

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Transforming Chronic Care

I am a physician and would like to refer a patient to this program.