Abstract
BackgroundPatients with multiple chronic conditions represent a growing segment for healthcare. The Chronic Care Model (CCM) supports leveraging community programs to support patients and their caregivers overwhelmed by their treatment plans, but this component has lagged behind the adoption of other model elements. Community Care Teams (CCTs) leverage partnerships between healthcare delivery systems and existing community programs to address this deficiency. There remains a gap in moving CCTs from pilot phase to sustainable full-scale programs. Therefore, the purpose of this study was to identify the cognitive and structural needs of clinicians, social workers, and nurse care coordinators to effectively refer appropriate patients to the CCT and the value these stakeholders derived from referring to and receiving feedback from the CCT. We then sought to translate this knowledge into an implementation toolkit to bridge implementation gaps.MethodsOur research process was guided by the Assess, Innovate, Develop, Engage, and Devolve (AIDED) implementation science framework. During the Assess process we conducted chart reviews, interviews, and observations and in Innovate and Develop phases, we worked with stakeholders to develop an implementation toolkit. The Engage and Devolve phases disseminate the toolkit through social networks of clinical champions and are ongoing.ResultsWe completed 14 chart reviews, 11 interviews, and 2 observations. From these, facilitators and barriers to CCT referrals and patient re-integration into primary care were identified. These insights informed the development of a toolkit with seven components to address implementation gaps identified by the researchers and stakeholders.ConclusionWe identified implementation gaps to sustaining the CCT program, a community-healthcare partnership, and used this information to build an implementation toolkit. We established liaisons with clinical champions to diffuse this information. The AIDED Model, not previously used in high-income countries’ primary care settings, proved adaptable and useful.
Highlights
Patients with multiple chronic conditions represent a growing segment for healthcare
Conceptual model Because our aims were primarily focused on the evaluation of current implementation processes to sustain the Community Care Team (CCT) in practice, we approached our methods with an implementation science lens [19]
All patients had physical capacity problems, but had additional capacity deficits that prompted their referral to the CCT
Summary
Patients with multiple chronic conditions represent a growing segment for healthcare. Community Care Teams (CCTs) leverage partnerships between healthcare delivery systems and existing community programs to address this deficiency. The prevalence of multiple chronic conditions, currently affecting three in four adults 65 and older, is growing [1, 2] These patients suffer from both a high burden of illness and a high burden of treatment [3]. Programs that leverage partnerships between healthcare systems and existing community programs address these deficiencies observed in the current structure of chronic care delivery. During the Blueprint for Health pilot, the program reduced patient hospitalizations, emergency department visits, and overall costs It has since been adopted by the majority of primary care practices in Vermont [10, 11]. Evaluation of community-healthcare system connectivity illustrated that community-based services and healthcare services operate in two separate worlds and perceived that it was not necessarily either parties job to connect or refer to the other [12]
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