The Chronic Care Model (CCM) is a promising framework for improving population health. This study evaluates the long-term impact of implementing a scalable, electronic health record enabled, and CCM-based population health program to replace a labor-intensive legacy program in 18 primary care practices. Interventions include point-of-care decision support, quality reporting, team-based care, patient engagement, and provider education. The results indicate that an EHR-enabled, team-based, and scalable population health strategy based on the CCM may be effective and efficient for managing population health.