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

Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH 03766, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 09/2010; 25 Suppl 4(S4):S574-80. DOI: 10.1007/s11606-010-1392-z
Source: PubMed


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.

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    • "Several innovative models to improve the quality of care revolve around the use of multidisciplinary teams and the patient-centered medical home (Wagner et al., 2001). The Chronic Care Model (CCM) has effectively improved chronic illnesses in community and academic settings (DiPiero et al., 2008;Stevens et al., 2010;Wagner et al., 2001). The model illustrates that 6 key elements, when integrated, lead to productive interactions between the patient and the health care team, resulting in improved outcomes. "
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    ABSTRACT: We implemented a quality improvement project for diabetes care in a faculty-resident internal medicine practice, using the Chronic Care Model framework. We created a planned visit clinic, used a stepwise medication algorithm, and self-management support. The intervention was effective for patients with glycohemoglobin A1c levels 10 or above (P = .0075) when compared with usual care after adjusting for all significant predictors. Compliance with foot examinations increased by 72% (P < .0001) and pneumococcal vaccinations by 25% (P = .0115). We believe that the Chronic Care Model can be successfully integrated into faculty-resident practices and provides a model for further exploration into disease management education in academic settings.
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    • "There are successful self-management programs for patients [2] [3] [4]. However , to achieve maximal effect the key elements of these programs need to be supported by health professionals [5], because their proficiency for self-management support correlates with better patient outcomes [6] [7] [8] [9] [10] [11]. In the United States (U.S.), patients have expressed the desire for self-management support [12], and selfmanagement support has been added to national healthcare quality indicators [13] [14] [15] [16] [17] [18]. "
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    ABSTRACT: OBJECTIVE: To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support. METHODS: Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback. RESULTS: Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001-0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001-0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P<0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning. CONCLUSION: The web-based self-management support training for health professionals was feasible and changed beliefs and confidence. PRACTICE IMPLICATIONS: The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.
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