Elements Of Chronic Care Model Research Articles

Healthcare Professionals' Perspectives on the Implementation of the Integrated Care Models for Chronic Patients.

Objective This study aimed toassess the understanding, adoption, and barriers to implementing integrated care for chronic diseases among healthcare professionals in Greece. By gathering insights from healthcare professionals directly involved in the care of patients with chronic conditions, this study sought to identify areas for improvement and inform future policy and strategic initiatives to enhance the quality of care and patient outcomes in Greece. Specific objectives included assessing healthcare professionals' knowledge and understanding of integrated care concepts, principles, and components in chronic disease management and exploring healthcare professionals' experiences in providing or participating in integrated care activities for patients with chronic diseases. Methods This study employed a census-based survey design to assess healthcare professionals' understanding, adoption, and barriers to the implementation of integrated care for chronic diseases in the Greek healthcare system. The sampling technique has been used to ensure the representation of different healthcare professions and regions in Greece. The survey questionnaire was structured based on the internationally recognized Chronic Care Model Elements Survey, specifically tailored to capture insights on integrated care for chronic illnesses in Greece. Healthcare professionals from diverse settings, including primary healthcare centers, public and private hospitals, specialty clinics, rehabilitation centers, home-based care services, and private sector practitioners, were targeted to gather comprehensive perspectives. Both urban and rural areas were included to ensure a representative sample, enabling an understanding of integrated care implementation in Greece. Results A total of 246 responses from healthcare professionals in Greece were collected and analyzed. An applicability index was constructed to evaluate the suitability of the integrated care system in Greece, utilizing variables collected during the survey. The reliability of the index was assessed using Cronbach's Alpha coefficient, which demonstrated a high value of 0.940, indicating strong internal consistency and correlation among the questions related to integrated care. However, the data collected for Greece exhibited a departure from a normal distribution using the Shapiro-Wilk test, suggesting the presence of barriers to the implementation of integrated care within the Greek healthcare system. Conclusions The study revealed several obstacles to integrated care implementation, encompassing organizational and individual factors, such as financial constraints, cultural differences, and regulatory challenges. Tackling these barriers will require a collective approach and close collaboration among multiple stakeholders to create an enabling context for adopting integrated care. Possible strategies involve resource allocation, fostering communication and cooperation among healthcare providers, and revising regulatory frameworks to facilitate integrated care practices. In order to achieve the national objectives of improving public health, the survey increases the focus on evidence-based public health.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review.

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Patient Assessment Chronic Illness Care (PACIC) and its associations with quality of life among Swiss patients with systemic sclerosis: a mixed methods study

BackgroundThe Chronic Care Model (CCM) is a longstanding and widely adopted model guiding chronic illness management. Little is known about how CCM elements are implemented in rare disease care or how patients’ care experiences relate to health-related quality of life (HRQoL). We engaged patients living with systemic sclerosis (SSc) to assess current care according to the CCM from the patient perspective and their HRQoL.MethodsWe employed an explanatory sequential mixed methods design. First, we conducted a cross-sectional quantitative survey (n = 101) using the Patient Assessment of Chronic Illness Care (PACIC) and Systemic Sclerosis Quality of Life (SScQoL) questionnaires. Next, we used data from individual patient interviews (n = 4) and one patient focus group (n = 4) to further explore care experiences of people living with SSc with a focus on the PACIC dimensions.ResultsThe mean overall PACIC score was 3.0/5.0 (95% CI 2.8–3.2, n = 100), indicating care was ‘never’ to ‘generally not’ aligned with the CCM. Lowest PACIC subscale scores related to ‘goal setting/tailoring’ (mean = 2.5, 95% CI 2.2–2.7) and ‘problem solving/contextual counselling’ (mean = 2.9, 95% CI 2.7–3.2). No significant correlations were identified between the mean PACIC and SScQoL scores. Interviews revealed patients frequently encounter major shortcomings in care including ‘experiencing organized care with limited participation’, ‘not knowing which strategies are effective or harmful’ and ‘feeling left alone with disease and psychosocial consequences’. Patients often responded to challenges by ‘dealing with the illness in tailored measure’, ‘taking over complex coordination of care’ and ‘relying on an accessible and trustworthy team’.ConclusionsThe low PACIC mean overall score is comparable to findings in patients with common chronic diseases. Key elements of the CCM have yet to be systematically implemented in Swiss SSc management. Identified gaps in care related to lack of shared decision-making, goal-setting and individual counselling-aspects that are essential for supporting patient self-management skills. Furthermore, there appears to be a lack of complex care coordination tailored to individual patient needs.

Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system.

Background:Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management. This qualitative case study examines perceptions of care among providers and administrators in a large, urban health system in Canada, and how the CCM might inform redesign of care to improve health system functioning.Methods:Sixteen semi-structured interviews were conducted between August 2014 and January 2016. Interpretive analysis was conducted to identify how informants perceive care among this population and the extent to which the design of heart failure care aligns with elements of the CCM.Results:Current care approaches could better align with CCM elements. Key changes to improve health system functioning for complex heart failure patients that align with the CCM include closing knowledge gaps, standardizing treatment, improving interdisciplinary communication and improving patient care pathways following hospital discharge.Conclusions:The CCM can be used to guide health system design and interventions for frail and multi-morbid heart failure patients. Addressing care- and service-delivery barriers has important clinical, administrative and economic implications.

Evaluating T1DM Patient Experience Using the Patient Assessment of Chronic Illness Care Survey

Aligning diabetes care with components of the Chronic Care Model (CCM) facilitates productive interactions between a proactive care team and an informed, activated patient, allows the care plan to be individualized, and can improve care and outcomes. The Patient Assessment of Chronic Illness Care (PACIC) survey assesses patient experience with CCM-based healthcare delivery components. In the Division of Diabetes and Endocrinology at Scripps Health, a large integrated health system in San Diego, CA, patients with T1DM have access to an interdisciplinary team of clinicians who provide care, education, and ongoing support. Guided by the CCM, an interactive care delivery system involving the endocrinologist, PCP, diabetes educator, RD, behavioral specialist and the patient was implemented to facilitate proactive and productive care but some interactions remained isolated. Between June and August 2017, the PACIC survey was administered by research assistants to N=47 adults with T1DM who have received care in the Division for at least 6 months. Overall, patients reported high satisfaction with care (M=4.77 out of 5; SD=0.56). Results also indicated high ratings for specific CCM elements, including Patient Activation, Delivery System Design/Decision Support, and Self-Management Support (M=4.29-4.55). Lower ratings were observed for Follow-Up/Coordination (M=3.81; SD=1.01), suggesting a need for enhanced post-visit contact with patients, referrals to community programs, dietitians, and counselors, and discussion of specialist appointments. In line with the Institute for Healthcare Improvement’s Triple Aim focused on improving the health of populations through optimization of health system performance, an RN with specialized experience in T1DM was added to the team as the Diabetes Care Manager to assist with follow-up and care coordination. The PACIC will be re-administered after 6 months to determine the impact on patient perceptions of follow-up/coordination between visits. Disclosure R. Morrisey: None. E. Kaczmar: None. A. Tsimikas: None. F.M. Arnold: None. T. Clark: None. J. McCallum: None. A.L. Fortmann: None.

A systematic review of chronic disease management interventions in primary care

BackgroundPrimary and community care are key settings for the effective management of long term conditions. We aimed to evaluate the pattern of health outcomes in chronic disease management interventions for adults with physical health problems implemented in primary or community care settings.MethodsThe methods were based on our previous review published in 2006. We performed database searches for articles published from 2006 to 2014 and conducted a systematic review with narrative synthesis using the Cochrane Effective Practice and Organisation of Care taxonomy to classify interventions and outcomes. The interventions were mapped to Chronic Care Model elements. The pattern of outcomes related to interventions was summarized by frequency of statistically significant improvements in health care provision and patient outcomes.ResultsA total of 9589 journal articles were retrieved from database searches and snowballing. After screening and verification, 165 articles that detailed 157 studies were included. There were few studies with Health Care Organization (1.9% of studies) or Community Resources (0.6% of studies) as the primary intervention element. Self-Management Support interventions (45.8% of studies) most frequently resulted in improvements in patient–level outcomes. Delivery System Design interventions (22.6% of studies) showed benefits in both professional and patient-level outcomes for a narrow range of conditions. Decision Support interventions (21.3% of studies) had impact limited to professional-level outcomes, in particular use of medications. The small number of studies of Clinical Information System interventions (8.9%) showed benefits for both professional- and patient-level outcomes.ConclusionsThe published literature has expanded substantially since 2006. This review confirms that Self-Management Support is the most frequent Chronic Care Model intervention that is associated with statistically significant improvements, predominately for diabetes and hypertension.

The primary health care in the emirate of Abu Dhabi: are they aligned with the chronic care model elements?

BackgroundAbu Dhabi is the capital of the United Arab Emirates (UAE) and the largest of the seven emirates in terms of land mass and population. Abu Dhabi emirate has three different geographical regions: the Central Capital District, the Eastern Region, and the Western Region. The health system has been regulated by the Health Authority – Abu Dhabi (HAAD), and has been provided by the Abu Dhabi Health Services Company (SEHA), since 2007. The UAE has a high population-burden of morbidity and mortality related to chronic diseases. This paper aims to characterize the Primary Health Care (PHC) public services in Abu Dhabi using the Chronic Care Model (CCM) as a framework.MethodsOfficially published data from HAAD, SEHA and the UAE Ministry of Health and Prevention was reviewed and abstracted. The Preferred Reporting Items Systematic Reviews and Meta-Analysis (PRISMA) statement was used as a baseline to review the PHC services through the CCM approach and to identify potential opportunities for improvement.ResultsThere are 38 SEHA Ambulatory Healthcare Centers (AHS) that provide PHC, from which 20 are located in the Eastern Region and the other 18 in the Central Capital District. The AHS adopted the principles of the patient-centered medical home model, aiming at providing structured, proactive and coordinated care. Implementation of the CCM elements aligns with those standards and is positively associated with the use of interventions targeting high-risk behaviors.ConclusionThe UAE has a strong foundation in place for addressing the growing problem of chronic diseases. The CCM has been shown to have beneficial effects on clinical outcomes reinforcing the PHC procedures and processes of care and should continue to inform systematic efforts to improve the care that lead to better lives for the Abu Dhabi community.

Considerations for developing chronic care system for traumatic brain injury based on comparisons of cancer survivorship and diabetes management care

Experts in traumatic brain injury (TBI) rehabilitation recently proposed the framing of TBI as a chronic disease rather than a discrete event. Within the framework of the Chronic Care Model (CCM), a systematic comparison of three diseases – cancer survivorship, diabetes management and TBI chronic care – was conducted regarding chronic needs and the management of those needs. In addition, comparisons of these conditions require comparative evaluations of disease management characteristics and the survivor concept. The analysis found diabetes is more established within the CCM, where care is integrated across specialists and primary care providers. No single comparison provides a full analogue for understanding the chronic care health delivery system for TBI, indicating the need for a separate model to address needs and resources for TBI survivors. The findings from this research can provide practitioners with a context to develop a robust continued care health system for TBI.Practitioner Summary: We examine development of a chronic care system for traumatic brain injury. We conducted a systematic comparison of Chronic Care Model elements of decision and information support. Development of capabilities using a benchmark of diabetes care, with additional insights from cancer care, provides insights for implementing TBI chronic care systems.

The chronic care model for type 2 diabetes: a systematic review.

The chronic care model (CCM) uses a systematic approach to restructure health care systems. The aim of this systematic review was to examine studies that evaluated different elements of the CCM in patients with type 2 diabetes mellitus (T2DM) and to assess the influence of the CCM on different clinical outcomes. There view was performed in the Medline and Cochrane Library electronic databases. The search was limited to randomized controlled trials conducted with T2DM patients. Studies were eligible for inclusion if they compared usual care with interventions that use done or more elements of the CCM and assessed the impact on clinical outcomes. After applying the eligibility criteria, 12 studies were included for data extraction. Of these, six showed evidence of effectiveness of the CCM for T2DM management in primary care as well as significant improvements in clinical outcomes. In the other six studies, no improvements regarding clinical outcomes were observed when comparing the intervention and control groups. Some limitations, such as a short follow-up period and a low number of patients, were observed. Some studies showed that the reorganization of health systems can improveT2DM care. However, it is possible that greater benefits could be obtained through combing all 6 elements of CCM.

Adherence to diabetes care processes at general practices in the National Capital Region-Delhi, India.

Aim:To assess the level of adherence to diabetes care processes, and associated clinic and patient factors at general practices in Delhi, India.Methods:We interviewed physicians (n = 23) and patients with diabetes (n = 406), and reviewed patient charts at general practices (government = 5; private = 18). We examined diabetes care processes, specifically measurement of weight, blood pressure (BP), glycated hemoglobin (HbA1c), lipids, electrocardiogram, dilated eye, and a foot examination in the last one year. We analyzed clinic and patient factors associated with a number of care processes achieved using multilevel Poisson regression model.Results:The average number of clinic visits per patient was 8.8/year (standard deviation = 5.7), and physicians had access to patient's previous records in only 19.7% of patients. Dilated eye exam, foot exam, and electrocardiogram were completed in 7.4%, 15.1%, and 29.1% of patients, respectively. An estimated 51.7%, 88.4%, and 28.1% had ≥1 measurement of HbA1c, BP, and lipids, respectively. Private clinics, physician access to patient's previous records, use of nonphysicians, patient education, and the presence of diabetes complication were positively associated with a number of care processes in the multivariable model.Conclusion:Adherence to diabetes care processes was suboptimal. Encouraging implementation of quality improvement strategies like Chronic Care Model elements at general practices may improve diabetes care.

Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care.

To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care. A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention. A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives. The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review.

BackgroundThe increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.MethodsThis systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.ResultsOf the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.ConclusionsWhile the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Implementation of the Chronic Care Model in Small Medical Practices Improves Cardiovascular Risk but Not Glycemic Control

OBJECTIVE To test whether the implementation of elements of the Chronic Care Model (CCM) via a specially trained practice nurse leads to an improved cardiovascular risk profile among type 2 diabetes patients. RESEARCH DESIGN AND METHODS This cluster randomized controlled trial with primary care physicians as the unit of randomization was conducted in the German part of Switzerland. Three hundred twenty-six type 2 diabetes patients (age >18 years; at least one glycosylated hemoglobin [HbA1c] level of ≥7.0% [53 mmol/mol] in the preceding year) from 30 primary care practices participated. The intervention included implementation of CCM elements and involvement of practice nurses in the care of type 2 diabetes patients. Primary outcome was HbA1c levels. The secondary outcomes were blood pressure (BP), LDL cholesterol, accordance with CCM (assessed by Patient Assessment of Chronic Illness Care [PACIC] questionnaire), and quality of life (assessed by the 36-item short-form health survey [SF-36]). RESULTS After 1 year, HbA1c levels decreased significantly in both groups with no significant difference between groups (-0.05% [-0.60 mmol/mol]; P = 0.708). Among intervention group patients, systolic BP (-3.63; P = 0.050), diastolic BP (-4.01; P < 0.001), LDL cholesterol (-0.21; P = 0.033), and PACIC subscores (P < 0.001 to 0.048) significantly improved compared with control group patients. No differences between groups were shown in the SF-36 subscales. CONCLUSIONS A chronic care approach according to the CCM and involving practice nurses in diabetes care improved the cardiovascular risk profile and is experienced by patients as a better structured care. Our study showed that care according to the CCM can be implemented even in small primary care practices, which still represent the usual structure in most European health care systems.

Organization of Diabetes Care

Organization of Diabetes Care

The importance of relational coordination and reciprocal learning for chronic illness care within primary care teams

Recent research from a complexity theory perspective suggests that implementation of complex models of care, such as the Chronic Care Model (CCM), requires strong relationships and learning capacities among primary care teams. Our primary aim was to assess the extent to which practice member perceptions of relational coordination and reciprocal learning were associated with the presence of CCM elements in community-based primary care practices. We used baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM and improve risk factor control for patients with Type 2 diabetes in small primary care practices. Practice members (i.e., physicians, nonphysician providers, and staff) completed baseline assessments, which included the Relational Coordination Scale, Reciprocal Learning Scale, and the Assessment of Chronic Illness Care (ACIC) survey, along with items assessing individual and clinic characteristics. To assess the association between Relational Coordination, Reciprocal Learning, and ACIC, we used a series of hierarchical linear regression models accounting for clustering of individual practice members within clinics and controlling for individual- and practice-level characteristics and tested for mediation effects. A total of 283 practice members from 39 clinics completed baseline measures. Relational Coordination scores were significantly and positively associated with ACIC scores (Model 1). When Reciprocal Learning was added, Relational Coordination remained a significant yet notably attenuated predictor of ACIC (Model 2). The mediation effect was significant (z = 9.3, p < .01); 24% of the association between Relational Coordination and ACIC scores was explained by Reciprocal Learning. Of the individual- and practice-level covariates included in Model 3, only the presence of an electronic medical record was significant; Relational Coordination and Reciprocal Learning remained significant independent predictors of ACIC. Efforts to implement complex models of care should incorporate strategies to strengthen relational coordination and reciprocal learning among team members.

The chronic care for age-related macular degeneration study (CHARMED): Study protocol for a randomized controlled trial

BackgroundNeovascular age-related macular degeneration is the leading cause of irreversible blindness in people 50 years of age or older in the developed world. As in other chronic diseases, several effective treatments are available, but in clinical daily practice there is an evidence performance gap. The Chronic Care Model represents an evidence-based framework for the care of chronically ill patients and aims at closing that gap. However, no data are available regarding patients with neovascular age-related macular degeneration.Methods/DesignCHARMED is a multicenter randomized controlled trial. The study challenges the hypothesis that the implementation of core elements of the Chronic Care Model (patient empowerment, delivering evidence based information, clinical information system, reminder system with structured follow up and frequent monitoring) via a specially trained Chronic Care Coach in Swiss centres for neovascular age-related macular degeneration results in better visual acuity (primary outcome) and an increased disease specific quality of life (secondary outcome) in patients with neovascular age-related macular degeneration. According to the power calculation, a total sample size of 352 patients is needed (drop out rate of 25%). 14 specialised medical doctors from leading ophtalmologic centres in Switzerland will include 25 patients. In each centre, a Chronic Care Coach will provide disease specific care according to the Chronic Care Model for intervention group. Patients from the control group will be treated as usual. Baseline measurements will be taken in month III - XII, starting in March 2011. Follow-up data will be collected after 6 months and 1 year.DiscussionMultiple studies have shown that implementing Chronic Care Model elements improve clinical outcomes as well as process parameters in different chronic diseases as osteoarthritis, depression or e.g. the cardiovascular risk profile of diabetes patients. This study will be the first to assess this approach in neovascular age-related macular degeneration. If our hypothesis will be confirmed, the implementation of this approach in routine care for patients with with neovascular age-related macular degeneration should be considered.Trial RegistrationCurrent controlled trials ISRCTN32507927.

Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care

BackgroundThere is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation.MethodsThe IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation.DiscussionThis pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada.Trial RegistrationClinicalTrials.gov: NCT00574808

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. To improve training for residents who provide chronic illness care in teaching practice settings. US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked. Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives. Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly. Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives. These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics.

To examine the chronic care model (CCM) as a framework for improving provider delivery of 5A tobacco cessation services. Cross-sectional surveys were used to obtain data from 497 health care providers in 60 primary care clinics serving low-income patients in New York City. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate the probability of full 5A service delivery, adjusting for provider covariates and clustering effects. We examined associations between provider delivery of 5A services, clinic implementation of CCM elements tailored for treating tobacco use, and the degree of CCM integration in clinics. Providers practicing in clinics with enhanced delivery system design, clinical information systems, and self-management support for cessation were 2.04-5.62 times more likely to perform all 5A services ( p<.05). CCM integration in clinics was also positively associated with 5As delivery. Compared with none, implementation of one to six CCM elements corresponded with a 3.69-30.9 increased odds of providers delivering the full spectrum of 5As ( p<.01). Findings suggest that the CCM facilitates provider adherence to the Public Health Service 5A clinical guideline. Achieving the full benefits of systems change may require synergistic adoption of all model components.

You can take your hat off

As an alliance of Western Melbourne health and wellbeing providers with the aim of combining systems redesign with health equity approaches, we’re interested in examining the role of partnership leaders. HealthWest builds on the Primary Care Partnership (Department of Human Services 2008) platform to broaden out both the scope and influence of the partnership. The HealthWest agenda now incorporates a much stronger advocacy and planning role through regular strategic forums. Members have also self funded the development of a business case for significant service system redesign that incorporates social influences on health. Formal members include community health services, local governments, hospitals, GP divisions, the local indigenous health service, psych disability support services, community nursing services, carers and ethno specific services working closely with Community and Neighbourhood Renewal, a range of refugee settlement services, government departments and community members. An important element of the HealthWest Partnership history is theWestBay-led Hospital Admission Risk Program diabetes project, which utilised the Chronic Care Model. Based on the ideas of American, Ed. Wagner (1998), the Chronic Care Model categorises, identifies and prioritises improvements and then systematically implements them using a team approach. It has the dual aims of creating an ‘active informed patient’ as well as a ‘proactive service team’. This framework has also been used to inform work with refugee and newly arrived services. Some examples of Chronic Care Model elements in practice: