Applying the Chronic Care Model across Multiple Conditions

1
Applying the Chronic Care Model across multiple
conditions A planned care quality improvement
initiative in the Indian Health System
Cindy Hupke, RN, MBA 1 Ty Reidhead, MD2 Bruce
Finke, MD2 Pat Lundgren, RN, EdD2 Lisa
Dolan-Branton, RN2 Gerald Langley, MS 1 Tracy
Jacobs, RN1 Lindsay Hunt, BA1 Kedar Mate, MD1
Don Goldmann, MD1 1Institute for Healthcare
Improvement, Cambridge, MA, 2 Indian Health
Service, Rockville, MD
Limitations
Background
Methods
Results

• Fourteen pilot Indian health facilities responded
  to a request for participation and were enrolled
  in the IPC collaborative based on the
  Breakthrough Series Collaborative model.
• From March 2007 to August 2008, microsystems
  (i.e. group of providers and patients at a
  facility) identified, tested, and implemented
  changes to improve chronic care and preventive
  processes and patient experience, by utilizing
• - organizational and community assessment
  tools
• - process flow diagrams
• - rapid cycle improvement methods
• (plan-do-study-act cycles)
• Sites shared learning through virtual meetings, a
  mutual listserv, and extranet.
• Composite measures were used
• - Intake screening bundles alcohol use,
  depression, body mass index, blood pressure,
  domestic violence and tobacco use
• - Cancer screening bundles screening for
  colorectal, cervical and breast cancer
• - Diabetes comprehensive measures includes key
  processes of care
• Data from sites were tracked using web-based
  monthly reporting tools on the extranet and
  analyzed using weighted averages in Microsoft
  Excel.

• Chronic and preventable conditions result in a
  high burden of illness in American Indian and
  Alaska Native peoples.
• In 2006 the IHS launched the Chronic Care
  Initiative (CCI) with the aim of improvement in
  clinical prevention and the management of chronic
  conditions using the framework of the Chronic
  Care Model.
• The Innovations in Planned Care (IPC)
  collaborative focuses on strengthening the
  relationship between the prepared, proactive care
  team and the patient, family, and community.
• Improvement is guided by measurement in four
  domains
• - preventive care
• - management of chronic
• conditions
• - patient experience of care
• - cost of care

• Participating sites self selected to participate
  and were motivated to improve.
• There was no control group to compare findings.
• Minimal data on cost of changes in the system was
  obtained.

Conclusions

• Using change concepts derived from the Chronic
  Care Model, collaborative teams improved clinical
  prevention, management of chronic conditions,
  patient and experience of care.
• Follow-up is planned to identify the optimal set
  and sequence of changes to ensure sustainability
  and spread of these improvements.