Better Chronic Disease Care Through Technology: Health Care Foundations Unveil $4.5 Million Program

Disease registries can help safety-net clinics ensure needed care

Five leading health care philanthropies have embarked on a two-year, $4.5 million effort to help community clinics and health centers that serve California’s uninsured and low-income residents adopt technology to improve chronic disease care.

Chronic disease management systems, also known as disease registries, are electronic tools that can help clinicians better deliver the right care at the right time to patients. Less complex and less expensive than electronic health records, these tools are regarded as a stepping stone toward more comprehensive health information technology systems.

In the first round of funding, 33 community clinics and health centers across California (see list below) will receive up to $40,000 each in matching funds to support software acquisition and training, with many of the clinics collaborating on implementation.

The funders of the “Tools for Quality” program are Blue Shield of California Foundation (BSCF); the California HealthCare Foundation (CHCF); the Community Clinics Initiative/Tides (CCI); Kaiser Permanente Southern California Region; and The California Endowment (TCE).

“Studies show that people with chronic conditions get recommended care only about half the time,” said Jonah Frohlich, CHCF senior program officer. “Disease registries can be used to track multiple chronic conditions, such as diabetes, hypertension, asthma, and depression. They help monitor progress and ensure better follow-up. The tools also help manage preventive care such as cancer screenings and immunizations.”

“The real power of disease registries is that they can be used as a tool for quality improvement by collecting and tracking data over time,” said Deborah Schwab, BSCF director of health and technology.

“Disease registries will enable these safety-net clinics to use a standardized set of clinical measures,” said Robert Phillips, senior program officer at TCE. “This is an essential step to understanding the health status of underserved populations in California. Disease registries can give clinics the ability to both see what’s happening with an individual patient, while tracking the health status of the tens of thousands of patients they see throughout the state,” he added.

“The safety-net clinic population, which tends to be low income, underserved, and often uninsured, is most vulnerable to disparities in treatment for chronic conditions. Disease registry tools can help overcome these disparities by ensuring greater continuity of care. This is an opportunity to help make lives better,” said Diana Bontá, vice president of public affairs for Kaiser Permanente Southern California Region.

The Tools for Quality program “builds on earlier efforts that we and other funding colleagues have made in bringing technology solutions into clinics to improve clinical care,” said Jane Stafford, CCI director. “Outside of California, few funders are working collaboratively on technology funding and technology-enabled quality improvement. But this coordinated approach provides greater funding capacity with a shared strategic goal. We expect it to make a difference in the care provided by these clinics and health centers.”

A constituency-based advisory committee will make recommendations on the future program direction, such as a second round of funding.

A short video on the benefits of disease registries is available.

Tools for Quality Grantees

The following clinics and clinic consortia were selected for the first round of grants. Grantees offer medical services in five California regions: the Central Valley, the Central Coast, Los Angeles County, San Diego County, and the San Francisco Bay Area. The 16 grantee organizations (in boldface) represent 33 clinics and health centers.

Community Health Center Network
Asian Health Services
Axis Community Health
La Clinica de La Raza
LifeLong Medical Care
Tiburcio Vasquez Health Center
Tri-City Health Center

San Benito Health Foundation
Community Health Centers of the Central Coast
Clinicas Del Camino Real

Central Valley Health Network
Clinica Sierra Vista
Inland Behavioral and Health Services
Livingston Medical Group
Valley Health Team

Southside Coalition of Community Health Centers
Central City Health Center
St. John’s Well Child and Family Center
South Central Family Health Center
T.H.E. Clinic, Inc.
UMMA Community Clinic
Asian Pacific Health Venture
Clinica Msr. Oscar A. Romero
Community Health Alliance of Pasadena
Mission City Community Network
Northeast Valley Health Center
Saban Free Clinic (nee The LA Free Clinic)
South Bay Family Health Center
Valley Community Clinic
Westside Family Health Center

Community Clinics Health Network
Borrego Community Health Foundation
Clinicas de Salud del Pueblo
NMA Comprehensive Health Center
La Maestra Family Clinics
Mountain Health and Community Services
Neighborhood Healthcare

About the Funding Organizations

Blue Shield of California Foundation is one of the largest healthcare grantmaking organizations in California. For more information, visit The Foundation was formed by Blue Shield of California, a not-for-profit corporation with more than 3.2 million members, 4,300 employees and 20 offices throughout California. For more information about the company, visit

The Community Clinics Initiative, a unique collaboration between Tides and The California Endowment, began in 1999 to provide resources, evidence-based programming and evaluation, education and training to support community health centers and clinics. Through information sharing and major grants, CCI acts as a catalyst to strengthen California’s community clinics and health centers to improve health outcomes in underserved communities. See

Kaiser Permanente, founded in 1945, is America’s largest not-for-profit health care organization, serving 8.1 million members in nine states and the District of Columbia. The Kaiser Permanente Community Benefit Program is committed to improving the health of communities by addressing health disparities through an integrated multi-dimensional collaborative approach. Kaiser Permanente partners with community groups, schools, and government organizations to provide social benefit activities that include assistance to the uninsured and special populations; training new health professionals; introducing new delivery and financing methods into the health care arena at large; and through their clinical research efforts, developing and sharing better ways to care for patients. See

The California Endowment‘s mission is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. See

About the California Health Care Foundation

The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.