Katie Coleman

Evidence On The Chronic Care Model In The New Millennium

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCMs effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.

Untangling Practice Redesign from Disease Management: How Do We Best Care for the Chronically Ill?

In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried and evaluated to improve health outcomes and reduce costs for chronically ill individuals. On one end of the spectrum are disease-management interventions--often organized by commercial vendors--that work with patients but do little to engage medical practice. On the other end are quality-improvement efforts aimed at redesigning the organization and delivery of primary care and better supporting patient self-management. This qualitative review finds that carve-out disease management interventions that target only patients may be less effective than those that also work to redesign care delivery. Imprecise nomenclature and poor study design methodology limit quantitative analysis. More innovation and research are needed to understand how disease-management components can be more meaningfully embedded within practice to improve patient care.

Integrated care for chronic conditions: The contribution of the ICCC Framework

OBJECTIVE The aim of this research is to highlight the current relevance of the Innovative Care for Chronic Conditions (ICCC) Framework, as a model for change in health systems towards better care for chronic conditions, as well as to assess its impact on health policy development and healthcare redesign to date. METHODS The authors reviewed the literature to identify initiatives designed and implemented following the ICCC Framework. They also reviewed the evidence on the effectiveness, cost-effectiveness and feasibility of the ICCC and the earlier Chronic Care Model (CCM) that inspired it. RESULTS The ICCC Framework has inspired a wide range of types of intervention and has been applied in a number of countries with diverse healthcare systems and socioeconomic contexts. The available evidence supports the effectiveness of this frameworks components, although no study explicitly assessing its comprehensive implementation at a health system level has been found. CONCLUSIONS As awareness of the need to reorient health systems towards better care for chronic patients grows, there is great potential for the ICCC Framework to serve as a road map for transformation, with its special emphasis on integration, and on the role of the community and of a positive political environment.

The Changes Involved in Patient-Centered Medical Home Transformation

In 2007, the major primary care professional societies collaboratively introduced a new model of primary care: the patient-centered medical home (PCMH). The published document outlines the basic attributes and expectations of a PCMH but not with the specificity needed to help interested clinicians and administrators make the necessary changes to their practice. To identify the specific changes required to become a medical home, the authors reviewed literature and sought the opinions of two multi-stakeholder groups. This article describes the eight consensus change concepts and 32 key changes that emerged from this process, and the evidence supporting their inclusion.

Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

PURPOSE The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODS We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTS After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. CONCLUSIONS The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

The safety net medical home initiative: transforming care for vulnerable populations.

Background:Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. Objectives:To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Design:Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Subjects:Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. Measures:We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. Results:All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Conclusions:Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

Improving care coordination in primary care.

Background:Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is received from multiple sources. Objectives:To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI). Research Design:In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A. Measures:SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions. Results:The Care Coordination Model elements—assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange—were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital. Conclusions:The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.

Spreading a Patient-Centered Medical Home Redesign A Case Study

Health care leaders and policymakers are turning to the patient-centered medical home (PCMH) model to contain costs, improve the quality of care, and create a more positive primary care work environment. We describe how Group Health, an integrated delivery system, developed and implemented a PCMH intervention that included standardized structural and practice level changes. This intervention was spread to a diverse set of 26 primary care practices in 14 months using Lean Management principles. Group Healths experience provides valuable insights that can be used to improve the design and implementation of future PCMH models.

Implications of Reassigning Patients for the Medical Home: A Case Study

PURPOSE Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative’s process of reassigning patients to new physicians as part of their medical home demonstration project. METHODS This work represents a subanalysis of the Group Health medical home pilot evaluation. Study participants include 8,005 adults who received primary care in 2006 and 2007 at an urban practice owned and operated by a not-for-profit integrated delivery system. Approximately one-quarter of patients were selected to be reassigned to a new physician. Primary care, emergency department, secure messaging, and telephone utilization were captured through automated sources. Patients’ experience was measured before and after implementation of the medical home for a subset of 1,098 patients. RESULTS Patients who were retained by their existing physicians were older, sicker, and had longer preexisting patient-doctor relationships. After reassignment, reassigned patients were less likely to use primary care services but equally likely to use the emergency department. They were no less satisfied with their care experience. CONCLUSIONS Informational and managerial continuity may mitigate deleterious effects of reassignment, but more must be done to actively bind reassigned patients to the medical home to improve relational continuity with younger, healthier patients.

Practice transformation in the safety net medical home initiative: a qualitative look.

Background:Transformation of primary care to patient-centered medical homes (PCMH) is challenging. Progress in transformation varied widely among practices involved in the Safety Net Medical Home Initiative. Objective:To study 3 successful practices to identify common characteristics and approaches. Research Design:We selected 3 diverse practices based on their improvement on the PCMH-A, a self-assessment instrument measuring progress toward becoming a PCMH. We interviewed 2–3 leaders from the each of 3 practices seeking information about their motivations for transforming, the methods used to make changes, and challenges and facilitators. Interview data were coded, themes developed, and conclusions drawn using qualitative research methods. Results:For these successful practices, the major motivators were a desire to improve quality of care, patient experience, or provider experience. Financial incentives played a minor role. All practices had engaged, visible leaders driving change, and all ultimately developed an effective quality improvement/practice change strategy that included the provision of trusted performance data at the provider level and an explicit process change strategy. Sequencing the work of PCMH transformation was important, and developing defined provider patient panels and building effective clinical teams facilitated making improvements to access and care delivery. Conclusions:Practice transformation is disruptive. To be successful, organizations need to have the will or motivation to change, explicit ideas or models on which to base change, and a culture and infrastructure that enables the execution of system changes.