Chronic Disease Management
Chronic Disease Management
MANDATORY
5 criteria
| Standard 3.1 NON-NEGOTIABLE · Standard 3: Chronic Disease Management Chronic Conditions Are Tracked in a Registry, Not Managed Only at the Point of Visit |
ASSESSMENT ASF-PHC-STD3-v3.0 |
| CR ADAPTED | TR FULL | SM ADAPTED | ST FULL |
| 3.1 NON-NEGOTIABLE L1 |
THE STANDARD Chronic Conditions Are Tracked in a Registry, Not Managed Only at the Point of Visit Every patient with a chronic condition — diabetes, hypertension, and other ongoing conditions — is entered into an active disease registry that tracks their status between visits, not managed only reactively during whatever visit happens to occur. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is every patient with a chronic condition entered into an active registry tracking their status? A real, maintained registry, not management limited to whatever happens to come up during a visit. Doc: Chronic disease registry documentation |
YES | PARTIAL | NO |
| 2 | Does the registry track status between visits, not only reflect data from the most recent encounter? Genuine, ongoing tracking, not a static snapshot from the last visit alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is the registry actively used to inform care, not maintained as a record separate from actual practice? Real, integrated use, not documentation disconnected from real clinical decisions. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Registry completeness review |
Reviews the registry for genuine, complete coverage of all patients with chronic conditions. |
| DOCUMENT Between-visit tracking review |
Reviews whether the registry genuinely tracks status between visits, not only at the point of care. |
| OBSERVE Registry use observation |
Observes whether the registry is genuinely consulted and used to inform actual care decisions. |
REFERENCES
- [11] Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers, with registry-based tracking established as foundational to achieving national quality benchmarks for chronic disease control in primary care.
| Standard 3.1 · Standard 3: Chronic Disease Management Guidance & Learning |
GUIDANCE ASF-PHC-STD3-v3.0 |
| WHY THIS STANDARD EXISTS |
Chronic disease outcomes depend on consistent, ongoing management over years, not just what happens to get addressed during an individual visit, and a registry is what allows the practice to actually know its full population of chronic disease patients and their real status — without it, a patient who simply doesn't come in for a while can silently fall out of active management entirely.
| WHAT GOOD LOOKS LIKE ✓ Every chronic disease patient is genuinely entered into an active registry. ✓ The registry tracks status between visits, not only at the point of care. ✓ The registry is genuinely used to inform real care decisions. |
WHAT FAILURE LOOKS LIKE ✗ Chronic conditions are managed only reactively during whatever visit occurs. ✗ The registry reflects only the most recent visit, with no between-visit tracking. ✗ A registry exists but isn't genuinely consulted in actual practice. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 The registry covers diabetes and hypertension well but less consistently other chronic conditions.
Every genuine chronic condition benefits from the same systematic tracking discipline.
2 Registry entry happens at diagnosis but isn't consistently maintained as a patient's status changes.
A registry needs to reflect a patient's current, real status to provide genuine ongoing value.
3 The registry exists and is accurate but is reviewed only during scheduled chronic-care visits, not more broadly.
Registry data has real value beyond the specific visit it was originally tied to.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current chronic disease management for reliance on point-of-visit care versus registry tracking.
Week 2 Build or strengthen a registry covering all patients with chronic conditions.
Week 3 Establish a process for keeping registry status genuinely current between visits.
Ongoing Integrate registry consultation into standard clinical workflow.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see the actual registry and confirm it reflects genuinely current patient status.
A specific, current registry reveals genuine practice, not documentation for its own sake.
Ask a clinician how they'd identify all their patients with a specific chronic condition.
A specific, confident answer reveals genuine registry use, not reliance on memory.
| E-LEARNING academy.gmj.ge/phc-std3-1-chronic-disease-registry — 30 min · complete before self-assessment |
| Standard 3.2 NON-NEGOTIABLE · Standard 3: Chronic Disease Management Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement |
ASSESSMENT ASF-PHC-STD3-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 3.2 NON-NEGOTIABLE L1 |
THE STANDARD Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement Chronic disease control is measured against specific, evidence-based targets — HbA1c below 7.0 percent for diabetes, blood pressure below 130/80 mmHg for hypertension — with the actual result documented, not a general sense that a patient seems to be doing better without a specific, measured number. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is chronic disease control measured against specific, evidence-based numeric targets, not general impression? A specific, documented number against a defined target, not a general sense of improvement. Doc: Control target measurement documentation |
YES | PARTIAL | NO |
| 2 | Is the actual result documented for each patient, not assumed from overall trend? A real, specific documented result, not an inference from general direction of change. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is the practice's own aggregate control rate calculated, not just individual results recorded without a genuine summary view? A real, calculated practice-level rate, not only scattered individual data points. Doc: Aggregate control rate documentation |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Target measurement review |
Reviews whether chronic disease control is measured against specific, evidence-based targets. |
| DOCUMENT Individual result documentation review |
Reviews whether actual results are documented for individual patients, not assumed from trend. |
| DOCUMENT Aggregate rate review |
Reviews whether the practice calculates its own genuine, aggregate control rate. |
REFERENCES
- [12] Documented national health data has found a persistent gap between the proportion of patients diagnosed with a chronic condition such as hypertension and the proportion with confirmed, documented control, establishing specific, measured control — not assumed improvement — as the genuine standard for chronic disease management quality.
| Standard 3.2 · Standard 3: Chronic Disease Management Guidance & Learning |
GUIDANCE ASF-PHC-STD3-v3.0 |
| WHY THIS STANDARD EXISTS |
National data show real, documented gaps between actual control rates and quality benchmarks — only a portion of patients with diagnosed hypertension have genuinely documented control — and a practice that doesn't measure against specific targets has no reliable way of knowing whether its patients are actually achieving control or simply seem improved without a real, confirmed number.
| WHAT GOOD LOOKS LIKE ✓ Control is measured against specific, evidence-based numeric targets. ✓ Actual results are documented for each patient, not assumed from trend. ✓ The practice calculates its own genuine, aggregate control rate. |
WHAT FAILURE LOOKS LIKE ✗ Improvement is assumed generally, without specific, measured targets. ✗ Results aren't documented, relying on general impression alone. ✗ No aggregate rate is calculated; only scattered individual data exists. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Targets are used for diabetes but not consistently for hypertension or other chronic conditions.
Every chronic condition with an established target deserves the same measurement discipline.
2 Individual results are documented but aren't consistently checked against the specific target at each visit.
A documented result that isn't compared against the target doesn't provide genuine, actionable information.
3 Aggregate rates are calculated periodically but not reviewed often enough to drive real, timely improvement.
Infrequent review limits how quickly a genuine gap in control translates into real corrective action.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current chronic disease measurement for reliance on general impression versus specific targets.
Week 2 Establish consistent documentation of actual results against defined targets for every chronic condition.
Week 3 Build a process for calculating and reviewing the practice's own aggregate control rate.
Ongoing Review aggregate control rates on a regular schedule to drive genuine improvement.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for the practice's actual, current aggregate control rate for a specific chronic condition.
A specific, real number reveals genuine measurement, not general impression.
Ask to see a specific patient's documented result compared against the defined target.
A real, specific comparison reveals whether measurement genuinely happens, not just data recording.
| E-LEARNING academy.gmj.ge/phc-std3-2-control-target-measurement — 30 min · complete before self-assessment |
| Standard 3.3 NON-NEGOTIABLE · Standard 3: Chronic Disease Management Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted |
ASSESSMENT ASF-PHC-STD3-v3.0 |
| CR N/A | TR FULL | SM ADAPTED | ST FULL |
| 3.3 NON-NEGOTIABLE L1 |
THE STANDARD Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted The practice proactively identifies patients with a chronic condition who are overdue for testing or follow-up — particularly those with poor control — and actively reaches out to them, not waiting passively for the patient to schedule their own next visit. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does the practice proactively identify patients with a chronic condition who are overdue for testing or follow-up? Real, active identification, not passive awareness that some patients may be overdue. Doc: Overdue patient identification process |
YES | PARTIAL | NO |
| 2 | Is there a specific, active outreach process for these patients, not just identification without follow-through? Genuine outreach, not identification that doesn't lead to real contact. Doc: Outreach record |
YES | PARTIAL | NO |
| 3 | Are patients with poor control specifically prioritized in this outreach, not treated the same as those with good control? Genuine prioritization of the highest-risk patients, not undifferentiated outreach. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Overdue identification process review |
Reviews the specific process for identifying patients overdue for chronic disease follow-up. |
| DOCUMENT Outreach record review |
Reviews evidence of genuine, active outreach to identified overdue patients. |
| DOCUMENT Prioritization review |
Reviews whether patients with poor control are specifically prioritized in outreach efforts. |
REFERENCES
- [13] Established diabetes quality improvement practice specifically includes a process to identify and proactively reach out to patients with poor glycemic control who have not had a test in more than four months, rather than waiting for the patient to independently schedule follow-up.
| Standard 3.3 · Standard 3: Chronic Disease Management Guidance & Learning |
GUIDANCE ASF-PHC-STD3-v3.0 |
| WHY THIS STANDARD EXISTS |
A patient with poorly controlled diabetes who simply doesn't return for a while represents genuine, real risk that compounds silently, and waiting passively for that patient to reach out themselves means the practice only reconnects with exactly the patients least likely to do so on their own.
| WHAT GOOD LOOKS LIKE ✓ Overdue patients are genuinely, actively identified through a real process. ✓ Active outreach genuinely follows identification, not just passive awareness. ✓ Patients with poor control are specifically prioritized in outreach. |
WHAT FAILURE LOOKS LIKE ✗ The practice waits passively for overdue patients to schedule their own visit. ✗ Identification happens but doesn't lead to genuine outreach. ✗ Outreach, if it happens, doesn't prioritize the highest-risk patients. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Outreach happens for diabetes but not consistently for other chronic conditions with similar follow-up needs.
Every chronic condition with a real follow-up requirement benefits from the same proactive discipline.
2 Identification happens but outreach attempts aren't tracked to confirm the patient was actually reached.
An outreach attempt that doesn't confirm actual contact provides limited real protective value.
3 Outreach happens once but isn't repeated if the initial attempt doesn't succeed.
A single missed attempt shouldn't end outreach for a genuinely high-risk overdue patient.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current follow-up practice for reliance on patient-initiated scheduling versus proactive outreach.
Week 2 Establish a systematic process for identifying overdue chronic disease patients.
Week 3 Build an active outreach process prioritizing patients with poor control.
Ongoing Track outreach attempts and successful contact rates.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for a real, recent example of a patient identified as overdue and how outreach actually happened.
A real example reveals whether this is genuine practice, not just policy language.
Ask how outreach differs for a patient with poor control versus one with good control.
A specific, thoughtful answer reveals genuine prioritization, not undifferentiated practice.
| E-LEARNING academy.gmj.ge/phc-std3-3-proactive-outreach — 30 min · complete before self-assessment |
| Standard 3.4 CORE · Standard 3: Chronic Disease Management Team-Based Care Coordinates Chronic Disease Management |
ASSESSMENT ASF-PHC-STD3-v3.0 |
| CR N/A | TR FULL | SM ADAPTED | ST FULL |
| 3.4 CORE L1 |
THE STANDARD Team-Based Care Coordinates Chronic Disease Management Chronic disease management genuinely involves the full care team — nurses, pharmacists, or other appropriate team members, not the physician alone — with real, coordinated roles, not the physician bearing the entire ongoing management burden without support. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does chronic disease management genuinely involve the full care team, not the physician alone? Real, coordinated team involvement, not physician-only management. Doc: Team-based care role documentation |
YES | PARTIAL | NO |
| 2 | Do team members have specific, defined roles in chronic disease management, not undefined or overlapping responsibility? Clear, specific role definition, not ambiguous shared responsibility that no one actually owns. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is there real evidence that team-based involvement is genuinely improving control rates, not just present without measurable effect? Genuine, measurable impact, not team involvement without demonstrated benefit. Doc: Team-based care outcome evidence |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE Team involvement observation |
Observes actual chronic disease management for genuine team member involvement, not physician-only care. |
| DOCUMENT Role definition review |
Reviews whether team members have specific, clearly defined roles in chronic disease management. |
| DOCUMENT Outcome evidence review |
Reviews evidence connecting team-based involvement to genuine control rate improvement. |
REFERENCES
- [14] Meta-analysis of team-based chronic disease care found that compared with usual care, team-based approaches involving patients, primary care providers, and additional healthcare professionals such as nurses or pharmacists were associated with greater reductions in blood glucose levels and greater improvements in blood pressure and lipid control.
| Standard 3.4 · Standard 3: Chronic Disease Management Guidance & Learning |
GUIDANCE ASF-PHC-STD3-v3.0 |
| WHY THIS STANDARD EXISTS |
Research shows team-based chronic disease care, including pharmacist involvement, measurably improves blood glucose and blood pressure control compared with physician-only management, and a practice that doesn't genuinely use its full team is both less effective for patients and places an unsustainable burden on the physician alone.
| WHAT GOOD LOOKS LIKE ✓ Chronic disease management genuinely involves the full care team. ✓ Team members have clear, specific, defined roles. ✓ Real evidence shows team-based care is genuinely improving control rates. |
WHAT FAILURE LOOKS LIKE ✗ Chronic disease management falls entirely on the physician alone. ✗ Team roles are ambiguous or overlapping, with no clear ownership. ✗ No evidence connects team involvement to genuine outcome improvement. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Nursing staff are genuinely involved but pharmacist expertise, where available, isn't systematically used.
Different team members bring genuinely distinct, complementary expertise to chronic disease management.
2 Team involvement is strong for diabetes but less developed for other chronic conditions.
The same team-based approach benefits management of any chronic condition, not diabetes alone.
3 Roles are defined but not consistently followed in actual daily practice.
A defined role that isn't genuinely followed doesn't provide the real coordination benefit this approach is meant to offer.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current chronic disease management for genuine team involvement versus physician-only care.
Week 2 Define specific, clear roles for team members in chronic disease management.
Week 3 Extend team-based involvement to chronic conditions beyond diabetes where appropriate.
Ongoing Track outcomes to confirm team-based involvement is genuinely improving control.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a nurse or other team member to describe their specific role in chronic disease management.
A specific, confident answer reveals genuine, defined involvement, not nominal team structure.
Ask how control rates have changed since team-based roles were established, if they have been.
A real, specific answer reveals genuine, measured impact.
| E-LEARNING academy.gmj.ge/phc-std3-4-team-based-care — 30 min · complete before self-assessment |
| Standard 3.5 NON-NEGOTIABLE · Standard 3: Chronic Disease Management Medication Adjustment Follows a Defined Process When Targets Aren't Met |
ASSESSMENT ASF-PHC-STD3-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 3.5 NON-NEGOTIABLE L1 |
THE STANDARD Medication Adjustment Follows a Defined Process When Targets Aren't Met When a patient's chronic disease control falls short of the defined target, medication or treatment adjustment follows a specific, defined process within a reasonable timeframe — not left unchanged indefinitely simply because the patient hasn't raised a concern. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does treatment adjustment follow a specific, defined process when a patient's control falls short of target? A real, defined process, not indefinite continuation of unchanged treatment. Doc: Treatment adjustment protocol documentation |
YES | PARTIAL | NO |
| 2 | Does adjustment happen within a reasonable, defined timeframe, not delayed indefinitely? A specific, genuine timeframe, not an open-ended delay. Doc: Adjustment timing record |
YES | PARTIAL | NO |
| 3 | Is there defined follow-up after a treatment adjustment to confirm it's actually working? Real, scheduled follow-up, not an adjustment made without checking whether it succeeded. Doc: Post-adjustment follow-up record |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Adjustment protocol review |
Reviews the specific, defined process for treatment adjustment when targets aren't met. |
| DOCUMENT Adjustment timing review |
Reviews records for a sample of patients with poor control to confirm adjustment happens within a reasonable timeframe. |
| DOCUMENT Follow-up after adjustment review |
Reviews whether defined follow-up occurs after a treatment adjustment to confirm effectiveness. |
REFERENCES
- [15] A hypertension management program that included evidence-based practice guidelines for pharmacological treatment adjustment and defined follow-up after medication changes was associated with measurably improved hypertension control rates, establishing a defined adjustment process, distinct from unchanged treatment, as genuinely effective practice.
| Standard 3.5 · Standard 3: Chronic Disease Management Guidance & Learning |
GUIDANCE ASF-PHC-STD3-v3.0 |
| WHY THIS STANDARD EXISTS |
Clinical inertia — continuing an unchanged treatment despite a patient genuinely not meeting their control target — is a well-documented, real pattern that allows a patient to remain in poor control far longer than clinically necessary, simply because no one actively revisited the treatment plan.
| WHAT GOOD LOOKS LIKE ✓ Treatment adjustment follows a specific, defined process when targets aren't met. ✓ Adjustment happens within a genuine, reasonable timeframe. ✓ Defined follow-up confirms whether an adjustment actually worked. |
WHAT FAILURE LOOKS LIKE ✗ Treatment remains unchanged indefinitely despite a patient not meeting target. ✗ Adjustment, when it happens, is significantly delayed with no defined timeframe. ✗ No follow-up confirms whether an adjustment succeeded. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Adjustment happens reliably for patients seen regularly but less consistently for those with sporadic visit patterns.
A patient with sporadic visits still deserves genuine, timely treatment adjustment when control is poor.
2 A defined process exists but isn't consistently followed when the clinician feels a patient's situation is 'close enough' to target.
A defined target deserves consistent application, not informal discretion about what counts as close enough.
3 Adjustments are made but follow-up to confirm effectiveness happens inconsistently.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current treatment adjustment practice for evidence of clinical inertia.
Week 2 Establish a specific, defined adjustment protocol with a genuine timeframe.
Week 3 Build defined follow-up after every treatment adjustment.
Ongoing Audit adjustment timing and follow-up completion for patients with poor control.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for a real, specific example of a patient whose treatment was adjusted after not meeting target.
A real, traceable example reveals whether adjustment genuinely happens promptly, not just in policy.
Ask what happens if a scheduled follow-up after adjustment doesn't occur.
A specific, confident answer reveals genuine tracking, not an assumption follow-up will happen.
| E-LEARNING academy.gmj.ge/phc-std3-5-treatment-adjustment — 30 min · complete before self-assessment |
Primary Health Clinic Standards — overviewFacility Classification — Which Type of Facility Are You?Standard 1 — Patient Registration & Continuity of CareStandard 2 — Preventive Care & ScreeningStandard 3 — Chronic Disease ManagementStandard 4 — Acute & Same-Day CareStandard 5 — Referral & Care CoordinationStandard 6 — Clinical Environment & SafetyStandard 7 — Governance & StaffingStandard 8 — Health & MigrationReferences & Index
STANDARD 3Chronic Disease Management3.1 Chronic Conditions Are Tracked in a Registry, Not Managed Only at the Point of Visit3.2 Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement3.3 Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted3.4 Team-Based Care Coordinates Chronic Disease Management3.5 Medication Adjustment Follows a Defined Process When Targets Aren't Met
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