Judith Schaefer, MPH

"The key to transforming health care delivery and improving care for people with multiple chronic conditions is creating genuine, collaborative partnerships between patients and their health care teams." 

Judith Schaefer, MPH

Research Associate, Kaiser Permanente Washington Health Research Institute


How can providers and patients become better partners in managing chronic illness? Answering this important research question requires exploring the challenges of treating complex illnesses in the context of complex lives. Judith Schaefer, MPH, works with patients and health care teams to understand changing behaviors: both personal health behaviors and changes in how health care is delivered.

Ms. Schaefer has extensive experience in ambulatory care team practice improvement, with specific expertise in care coordination, care for people with multiple chronic conditions, team-based care, and patient self-management support. Ms. Schaefer directs learning networks for Primary Care Transformation–Learning from Effective Ambulatory Practices, a Robert Wood Johnson Foundation (RWJF) program, and for the Agency for Healthcare Research and Quality (AHRQ)’s Multiple Chronic Conditions Research Network (MCCRN), where she led the development of a conceptual framework on care. She also provided guidance for AHRQ’s Team-Based Care Measures development project.

Ms. Schaefer provides technical assistance to practices and researchers in expanding the reach of primary care through implementation of the patient-centered medical home and community partnerships. She has provided expertise for the RWJF Aligning Forces for Quality initiative, developed curricula and teaching materials for the Commonwealth Fund Safety Net Medical Home Initiative, and for CoachMedicalHome.

She is the author of “Partnering in Self-Management Support: A Toolkit for Clinicians,” for the Self-Management Support Learning Community for New Health Partnerships, a RWJF funded program at the Institute for Healthcare Improvement. Previously, she co-chaired the Self-Management Workgroup for the Bureau of Primary Health Care’s Health Disparities Collaboratives.

Research interests and experience 

  • Behavior Change

    Self-management support;  provider/team training (CME); brief behavioral interventions; motivational  interviewing

  • Chronic Illness Management

    Multi-morbidity and complex chronic care;  collaborative approaches to transforming health care systems; patient-centered  care; consumer engagement in quality

  • Health Services & Economics

    Conceptual frameworks and modeling; intervention description methods; evaluation of  health care systems; quality improvement methodology; patient-centered medical  home

  • Preventive Medicine

    Appropriate use of preventive interventions; communication methods for preventive intervention; shared decision making

Recent publications

Shoemaker SJ, Parchman ML, Fuda KK, Schaefer J, Levin J, Hunt M, Ricciardi R. A review of instruments to measure interprofessional team-based primary care. J Interprof Care. 2016 Jul;30(4):423-32. doi: 10.3109/13561820.2016.1154023. Epub 2016 May 21. PubMed

Johnson KE, Coleman K, Phillips KE, Austin BT, Daniel DM, Ridpath J, Schaefer J, Wagner EH. Development of a facilitation curriculum to support primary care transformation: the "Coach Medical Home" curriculum. Med Care. 2014 Nov;52 Suppl 4:S26-32. doi: 10.1097/MLR.0000000000000240.

Grembowski D, Schaefer J, Johnson KE, Fischer H, Moore SL, Tai-Seale M, Ricciardi R, Fraser JR, Miller D, Leroy L. A conceptual model of the role of complexity in the care of patients with multiple chronic conditions. Med Care. 2014;52 Suppl 3:S7-S14. doi: 10.1097/MLR.0000000000000045. PubMed

Daniel DM, Wagner EH, Coleman K, Schaefer JK, Austin BT, Abrams MK, Phillips KE, Sugarman JR. Assessing progress toward becoming a patient-centered medical home: an assessment tool for practice transformation. Health Serv Res. 2013 Dec;48(6 Pt 1):1879-97. doi: 10.1111/1475-6773.12111. Epub 2013 Oct 21. PubMed


Latest release

Medical Care special issue features Safety Net Medical Home Initiative

Oct. 15, 2014—Group Health helped pioneer the patient-centered medical home. Now a team from GHRI’s MacColl Center has co-led, with Qualis Health, the largest initiative to spread this model of care to safety net practices that treat vulnerable populations.