August 2008

Grant Results

SUMMARY

From 2005 to 2007, project staff at the Association of American Medical Colleges provided education and coaching to teams at 22 academic health centers that were implementing the Chronic Care Model — a system to improve the care of chronically ill patients.

Key Results

  • Teams that focused on diabetes showed improvements in process measures that correlate with quality diabetes care, such as giving patients regular eye and foot exams. Improvement in clinical patient outcomes, such as lowered LDL (bad cholesterol) or lowered hemoglobin A1C (blood sugar count), was mixed.
  • Most of the teams were able to make changes to their educational programs in chronic illness care that also aligned with teaching the competencies required by the Accreditation Council for Graduate Medical Education (ACGME).

Funding
The Robert Wood Johnson Foundation (RWJF) provided $132,726 from 2005 to 2007 for this unsolicited project.

 See Grant Detail & Contact Information
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THE PROBLEM

The Chronic Care Model, created by Ed Wagner, M.D., and his team at the MacColl Institute for Health Care Innovation, introduced a system for the effective management of chronic illness. It called for clinical teamwork in collaboration with the patient to replace the traditionally physician-centered health care delivery model. The model has six key elements:

  • Empower and prepare patients to manage their health and health care.
  • Assure the delivery of effective and efficient clinical care and self-management support.
  • Promote clinical care that is consistent with scientific evidence and patient preferences.
  • Organize patient and population data to facilitate effective and efficient care.
  • Create a culture, organization and mechanisms that promote safe, high-quality care.
  • Mobilize community resources to meet needs of patients.

For further details about the Chronic Care Model, see Appendix 1.

A critical element of the Chronic Care Model — engaging the patient as an informed, active participant in the care process — would require substantial change in the culture of any health care institution, according to David P. Stevens, M.D., at the Association of American Medical Colleges and RWJF project director. However, it was particularly challenging for academic health centers.

Academic health centers are complex organizations with missions that embrace research and education as well as patient care. Physicians working in these settings must attend to an array of obligations — not only patient care in the clinic, but also teaching, publishing articles and other administrative and leadership tasks.

Academic health centers often are loosely organized, with physicians, departments and clinics retaining much autonomy. To get the attention of staff and the commitment of resources to support a change effort, one must engage leadership at all levels of the organization.

To address these challenges, beginning in June 2005, the Association of American Medical Colleges' Institute for Improving Clinical Care joined with RWJF's Improving Chronic Illness Care national program, headed by Wagner, to form the Academic Chronic Care Collaborative (the Collaborative).

The Collaborative was a national initiative composed of 48 teams from 22 medical schools and teaching hospitals. As part of the Collaborative, the teams committed to incorporating the elements of the Chronic Care Model into ambulatory care practices that serve as sites for residency and nursing training programs. Ambulatory settings were the focus of the Collaborative because it is at such settings that medical and nursing students typically learn to treat most patients with chronic illnesses.

The teams consisted of 3 to 10 members and included physicians, nurses, medical residents, nursing trainees, administrators, data analysts and others. (See list of participating academic health centers, Appendix 2.) The Collaborative also required teams to have the support of top institutional leaders — the team's department chair, residency program director and/or clinic manager.

The Collaborative offered the teams a structured opportunity to develop strategies to change their complex institutions.

The RWJF grant enabled the Collaborative to hire faculty consultants and other specialists to provide instruction and coaching to the teams as they worked to institutionalize the Chronic Care Model in their clinical settings and educational programs.

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RWJF STRATEGY

For many years, the Robert Wood Johnson Foundation has worked to ensure that all Americans, especially those with chronic conditions, receive quality health care in outpatient settings. Specifically, we supported efforts to create national and local pressure for more transparency as a way to drive quality improvement, we sought to engage consumers and purchasers in understanding and assessing quality, and we tracked progress in achieving better care. Our support for the Chronic Care Model was an important aspect of our efforts to improve the quality of care for the chronically ill.

A key aspect of the work conducted under the current grant was the use of the Breakthrough Series Collaborative, created by the Institute for Healthcare Improvement as a short-term (6- to 15-month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area. RWJF has used the Breakthrough Series in many of its programs and grant-funded projects.

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THE PROJECT

The goals of the project were to:

  • Implement the Chronic Care Model in ambulatory care settings in 22 medical schools and teaching hospitals.
  • Improve patient care as reflected in clinical outcomes.
  • Transform medical and nursing educational programs to reflect the tenets of excellent chronic illness care.
  • Define learner competencies that should be the standard for medical and nursing education in the field of chronic illness care.

Activities

Creating a Learning Community
To enable teams to learn from one another, the Collaborative used the Breakthrough Series model from the Institute for Healthcare Improvement. This model brings together teams from health care organizations to devise improvements in a focused area over the course of several months. The teams return home between learning sessions and implement and continually refine the changes.

Collaborative project staff and consultants conducted three 2-day learning sessions (in September 2005, January 2006 and May 2006) to guide teams as they considered improvements in each aspect of the Chronic Care Model.

Project staff hosted the January 2006 session online using WebEx, a web-based conferencing program. Staff held the other two sessions in person in Chicago. About 150 people attended each session.

Implementing Practice Changes
In the months between learning sessions, the teams worked to implement changes in their ambulatory clinic training sites by focusing on one or more chronic conditions. Most teams chose diabetes because that condition has well-defined criteria for high-quality care.

The teaching clinics often were poorly organized for chronic illness care. Teams redesigned simple structures, such as scheduling, to assure that patients saw the same resident at each visit. Each month, teams electronically submitted to the Collaborative data from registry reports that included both process and outcome measures related to the team's disease focus.

Collaborative faculty and guest speakers conducted monthly conference calls with team members that focused on difficult aspects of the Chronic Care Model, team challenges and successes and ways to spread changes teams had implemented.

Instituting Educational Changes
To help teams institute changes in their educational programs, Collaborative faculty and staff generated for each team what they called an "educational change package," incorporating evidence-based strategies and interventions. This guide also allowed the teams to create a set of measures to track changes they made in their programs.

Collaborative faculty members worked with teams to define educational objectives that met the requirements of the Accreditation Council of Graduate Medical Education (ACGME) and the specific applications of the Chronic Care Model. The Collaborative required all teams to report on two selected measures of educational outcomes. Additional outcome measures were optional.

Because many elements of the Chronic Care Model were unfamiliar to all team members, the Collaborative defined "learners" as all clinicians, including attending physicians, residents and students.

Communications

The Collaborative communicated its progress through articles in the AAMC Reporter (circulation 7,000) and the journal Academic Medicine (circulation 4,200). To highlight the work of the teams, the Academic Chronic Care Collaborative held its October 2006 meeting in conjunction with the annual meeting of the Association of American Medical Colleges in Seattle. Project Director Stevens presented the work of the Collaborative at numerous national and international conferences.

Other Funding

The Delmarva Foundation provided $348,000 in additional project support.

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RESULTS

Collaborative staff members reported that as of April 2008, they were preparing a full report of results of the project for submission to a peer-reviewed journal. These preliminary results come from their final report to RWJF and the site teams' published articles.

Patient Care Processes and Outcomes

  • Teams that had chosen diabetes as their chronic illness showed considerable improvement in process measurements, but improvement in clinical patient outcomes was more difficult to achieve. For example:
    • After implementing the Chronic Care Model, the Duke Outpatient Clinic of the Duke University Medical Center tracked its progress for 18 months. The team reported improvements in a number of process measures correlated with quality diabetes care, including:
      • The percentages of patients receiving dilated eye exams and flu and pneumococcal vaccinations.
      • The measurement of more than two hemoglobin A1Cs (blood sugar counts) in the past year.
      • A documented comprehensive foot exam in the past year.
      • A documented patient self-management goal in the past year.
    • Clinical results were mixed:
      • The percentage of patients with LDL (bad cholesterol) of less than 100 in the past year improved.
      • The percentage of patients with hemoglobin A1Cs of less than 7 percent and blood pressure of less than 130/80 did not improve.

For more details on Duke's experience, see the August 2007 ACGME Bulletin.

Transforming Educational Programs

  • Most teams made changes to their chronic illness curricula. For example, Summa Health System in Akron, Ohio, implemented the following new practices:
    • Residents began working in teams with a nurse practitioner and a clinical expert to follow diabetic patients more closely. They were aided by the use of clinical decision-making tools for glucose, blood pressure and LDL control, as well as patient registries to track appointments or tests that patients needed. Nurses helped mobilize pharmacists, social workers and behavioral scientists for follow-up care.
    • Small groups of residents worked with a clinical psychologist to develop skills to help patients manage their own illnesses. Residents learned to use tools to help patients set goals and practiced their new skills by using role-play.
    • Faculty developed 10- to 12-minute podcasts on diabetes care decision-making that residents could download from the Internet and listen to at their convenience.

    Summa team members quoted a second-year medical resident who expressed satisfaction with the new educational interventions: "I don't feel alone now when I'm trying to see these patients with long-term illness. I don't dread their appointments because I know there is a team working with me" (from August 2007 ACGME Bulletin).
  • Most teams were able to align their educational changes with strategies for addressing the six competencies required by the ACGME. The changes aligned particularly well with two competencies, characterized as "difficult" ones by the project director. These are:
    • Practice-based learning and improvement, which requires skills such as analyzing one's own practice for needed improvements, using evidence from scientific studies, applying research and statistical methods, using information technology and facilitating the learning of others.
    • Systems-based practice, which requires skills such as understanding the interaction of one's practice with the larger system; practicing cost-effective health care; advocating for patients within the health care system; and partnering with health care managers and health care providers to assess, coordinate and improve health care.
  • Four residency programs in institutions with Collaborative teams were selected to take part in the Internal Medicine Residency Review Committee Educational Innovations Project sponsored by the ACGME. The programs submitted proposals that included fundamental redesign of their residency programs anchored in their work in the Collaborative. For example:
    • In November 2006, the University of Cincinnati implemented a new internal medicine residency program with a one-year block ambulatory practice to improve continuity for both residents and patients. One half-day per week was reserved for team meetings on improvement strategies and educational sessions for residents.

      By June 2007, process outcomes for patients and residents had improved:
      • The number of patients with hypertension decreased by 26 percent.
      • The number of patients who received tetanus vaccinations increased 260 percent.
      • The percentage of residents reporting that they had a "healing relationship" with their patients rose from 15 percent to 50 percent.
      • The likelihood that a patient spoke directly to his or her primary care physician when calling or visiting the practice exceeded 80 percent, a 30 percent improvement.

For more details on Cincinnati's redesign of its residency program, see the August 2007 ACGME Bulletin.

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SIGNIFICANCE TO THE FIELD

Clinicians who participated in Collaborative teams reported being reenergized in their careers. The project allowed teams to probe new questions about quality improvement and to present their work both to their own institutions and at national meetings. A number of the medical schools reported that they were attracting more residents to the teams' residency programs and retaining more residents in those programs in the primary care specialty.

Stevens believes this shift bodes well for primary care medicine. "These young doctors come in with the will to do the right thing," he said. "We give them the ideas, the evidence and a strategy to execute it. … We have had residents who turn around and become our champions."

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LESSONS LEARNED

  1. Require teams to get institutional support as a condition of being part of a collaborative effort. Getting the backing of their institutions allowed teams to overcome the inertia that had prevented previous quality improvement work by securing the necessary time and resources. (Project Director)
  2. Having a clear structure keeps teams focused and on track. The Collaborative provided the guidance, infrastructure and expectations to keep teams on task and moving forward. (Project Director)
  3. Emphasize the importance of teamwork. The teams were able to break down the traditional hierarchy of clinical roles, which helped facilitate change. Teamwork created a sense of ownership by many health professionals and staff and sparked enthusiasm. Incremental tests of change were more readily implemented, met with less internal resistance, reduced individual workload and increased job satisfaction. (Project Director)
  4. Get committed senior leaders who are supportive of the work of improvement teams. Senior leaders gave teams a clear agenda for improvement and expected from them regular reports about their progress. Senior leaders also cleared the way for busy team members to participate in learning sessions, use work time to redesign clinic systems and attend scheduled team meetings. (Project Director)
  5. Exploit those aspects of the "culture" of academia that actually support change and innovation. These include competition, aspiration for excellence, focus on the research mission, comfort with data and commitment to the educational mission. (Project Director)
  6. Getting resources to support local transformational change is a constant challenge. Teams underwrote all costs of the learning sessions, including airfare, hotel, meeting registration and time spent away from their clinics. To minimize costs, the Academic Chronic Care Collaborative conducted one 2-day learning session over the Web. (Project Director)
  7. Rely heavily on communication technology, such as Web sites and listservs, to support collaborative projects. In addition to reducing travel costs of in-person learning sessions, Web technology allowed the session leaders to conduct polls of the audience and to field virtual questions. Participants talked and shared ideas and strategies through an online "chat" function. Electronic media also were useful for updating participants who were new to the Collaborative. (Project Director)

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AFTER THE GRANT

The Collaborative teams continue to submit monthly progress reports on a voluntary basis, which are reviewed by Collaborative faculty.

As of March 2008, the Collaborative faculty and clinicians at the Collaborative sites had submitted more than two dozen articles about the project to academic journals. See Bibliography for publication details.

In December 2006, the California Healthcare Foundation — in partnership with RWJF's Improving Chronic Illness Care national program and in collaboration with the Association of American Medical Colleges — created the California Academic Chronic Care Collaborative to incorporate the Chronic Care Model in academic health centers in California.

As of June 2007, the daily operation of the Academic Chronic Care Collaborative and its Web site was transferred to the RWJF Improving Chronic Illness Care national program.

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GRANT DETAILS & CONTACT INFORMATION

Project

Engaging Health Centers' Participation in the National Academic Chronic Care Collaborative

Grantee

Association of American Medical Colleges (Washington,  DC)

  • Amount: $ 132,726
    Dates: September 2005 to February 2007
    ID#:  055278

Contact

David P. Stevens, M.D.
(202) 828-0418
dstevens@aamc.org

Web Site

http://www.improvingchroniccare.org

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APPENDICES


Appendix 1

Key Elements of the Chronic Care Model

Under the Chronic Care Model*:

  • Self-management support: Clinicians encourage chronic patients to participate in setting goals and fine-tuning treatment.
  • Delivery system design: Clinical staff has defined roles and tasks and follows up with patients regularly to support them in managing their own diseases.
  • Decision support: Clinicians use explicit guidelines, whether the question is scientific (drug doses) or psychological (how best to motivate overweight diabetics to diet).
  • Clinical information systems: The office uses computers efficiently to deliver disease management information, including care guidelines, test results and even pop-up reminders about individual patients.
  • Health system: The health system, as a whole, pursues excellence visibly — creating strategies for improvement as well as encouraging open communication about errors and failings.
  • The community: Doctor's offices and clinics know about existing community resources that can help their patients and they encourage them to participate.

*Excerpted from the Institute for Healthcare Improvement Web site.


Appendix 2

Institutions Participating in the Academic Chronic Care Collaborative

  • Case Western Reserve University School of Medicine, Cleveland, Ohio
  • Duke University Medical Center, Durham, N.C.
  • Emory Healthcare, Atlanta, Ga.
  • Harbor-UCLA Medical Center, Torrance, Calif.
  • Lehigh Valley Hospital Network (Penn State School of Medicine), Hershey, Pa.
  • Medical College of Wisconsin, Milwaukee, Wis.
  • Montefiore Medical Center, New York, N.Y.
  • Oregon Health and Science University, Portland, Ore.
  • Southern Illinois University, Springfield, Ill.
  • St. Luke's-Roosevelt Hospital Center, New York, N.Y.
  • Summa Health System, Akron, Ohio
  • University of Alabama at Birmingham, Birmingham, Ala.
  • University of Cincinnati Medical Center, Cincinnati, Ohio
  • University of Colorado Hospital, Aurora, Colo.
  • University of Kentucky Medical School, Lexington, Ky.
  • University of Louisville Health Sciences Center, Louisville, Ky.
  • University of Michigan School of Medicine, Ann Arbor, Mich.
  • University of Minnesota Medical School, Duluth, Minn.
  • University of Nebraska Medical Center, Omaha, Neb.
  • University of South Carolina School of Medicine, Columbia, S.C.
  • VA Connecticut Healthcare System (Yale University and University of Connecticut), Newington and West Haven, Conn.
  • Vanderbilt University Medical Center, Nashville, Tenn.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Blumenthal A. "Chronic Care Initiative Spurs Changes in Teaching and in Treatment." AAMC Reporter, 16(7): 6–7, 2007.

Bowen JL, Hindmarsh M, Johnson J, Provost L, Sixta C, Stevens DP, Wagner EH and Woods D. "Developing and Implementing a Tool to Assess Chronic Illness Care in Educational Settings." Unpublished.

Bowen JL, Hindmarsh M, Johnson J, Provost L, Sixta C, Stevens DP, Wagner EH and Woods D. "Developing Measures of Educational Change for Academic Health Centers Implementing the Chronic Care Model in Teaching Clinics." Unpublished.

Bowen JL, Hindmarsh M, Johnson J, Provost L, Sixta C, Stevens DP, Wagner EH and Woods D. "Implementing the Chronic Care Model in Academic Teaching Practices: Educational Methods and Outcomes." Unpublished.

Choe HM, Bernstein S, Cooke D, Stutz D and Standiford C. "Improving Diabetic Foot Examinations in Primary Care with Trained Medical Assistants." Unpublished.

Coca FA. "Implementing the Chronic Care Model in an Academic Setting: A Resident's Perspective." Seminars in Medical Practice, 10: 1–8, 2007.

DiPiero A, Dorr D, Kelso C and Bowen JL. "Integrating Systematic Chronic Care for Diabetes into an Academic General Internal Medicine Practice." Unpublished.

"Economic Benefits of Chronic Care Model Using NPs." Summa Internal Medicine. Unpublished.

Francis MD, Hingle ST and Varney A. "Changing Clinical Practice in the Southern Illinois University Ambulatory General Medicine Clinic to Improve Chronic Illness Care and Education." ACGME Bulletin, 15–18, August 2007. Also available online.

Hariharan J. "Application of the Chronic Care Model in Faculty-Resident Practices." Quality and Safety in Health Care. In press.

Harrison RV, Standiford CJ, Green LA and Bernstein SJ. "Integrating Education into Primary Care Quality and Cost Improvement at an Academic Medical Center." Journal of Continuing Education in the Health Professions, 26(4): 268–284, 2006.

Jones R, Sweet D, Radwany S, Clough L and Zarconi J. "Redesigning Care for Chronic Disease: Using Clinical Outcomes to Drive Curriculum and Patient Care in a Residency Based Clinic." ACGME Bulletin, 18–25, August 2007. Also available online.

Kelso C, DiPiero A, Dorr D and Bowen JL. "Assessing the Educational Impact of Integrating Systematic Chronic Care for Diabetes into an Internal Medicine Residency Practice." Unpublished.

Kirsh S and Aron DC. "Integrating the Chronic Care Model and the ACGME Competencies: Using Shared Medical Appointments to Focus on Systems-Based Practice." Quality and Safety in Health Care. In press.

Johnson J, Woods D, Bowen JL, Hindmarsh M, Provost L, Sixta C, Stevens DP and Wagner EH. "Using an Electronic Team Survey to Explore the Effects of the Chronic Care Collaborative on Teams and Teamwork." Unpublished.

"Outcome Change in Chronic Disease in an Academic Clinic Setting: Family Medicine and Internal Medicine." Summa Internal Medicine. Unpublished.

Provost L, Bowen JL, Hindmarsh M, Johnson J, Sixta C, Stevens DP, Wagner EH and Woods D. "Clinical Outcomes from an Academic Chronic Care Collaborative." Unpublished.

Sergent J. "40 years of Change Good for Medicine." Tennessean, October 7, 2006.

Sixta C, Bowen JL, Hindmarsh M, Johnson J, Provost L, Stevens DP, Wagner EH and Woods D. "Implementing the Chronic Care Model in Academic Institutions." Unpublished.

Stevens DP and Wagner EH. "Transform Residency Training in Chronic Illness Care — Now." Academic Medicine, 81(8): 685–687, 2006.

Trinh JV, McNeill D, Heflin M, Bowlby L and Weinerth J. "The Academic Chronic Care Collaborative Experience and Resident Education in Ambulatory Medicine at Duke University." ACGME Bulletin, 8–10, August 2007. Also available online.

University of Colorado Family Medicine Residency Program. "Curricular Redesign: The Intersection of the Chronic Care Model and ACGME Competencies." Unpublished.

Vanderbilt University Medical Center. "Bridges to Excellence: Experiences with the Academic Chronic Care Collaborative." In press.

Warm EJ, Boex J and Rouan G. "The Academic Chronic Care Collaborative and the Educational Innovations Project (EIP): The University of Cincinnati (UC) Academic Health Center Experience." ACGME Bulletin, 11–14, August 2007. Also available online.

Woods D, Johnson J, Bowen JL, Hindmarsh M, Provost L, Sixta C, Stevens DP and Wagner EH. "Stories from the Field: Implementing the Chronic Care Model in Academic Settings." Unpublished.

Woods D, Johnson J, Bowen JL, Hindmarsh M, Provost L, Sixta C, Stevens DP and Wagner EH. "Transforming the Academic Institution into a Learning Organization: The Role of the Chronic Care Collaborative in Facilitating Change." Unpublished.

Survey Instruments

"Academic Chronic Care Collaborative Concluding Questionnaire," Association of American Medical Colleges, fielded March–April 2007.

World Wide Web Sites

www.aamc.org/iicc. Web site created to enhance public access to information about the Academic Chronic Care Collaborative. Includes application and institution information, conference summaries and presentations, and general reference information. Also served as a portal to the Collaborative's private site, a password-protected Web site for Collaborative participants. Washington, D.C.: Association of American Medical Colleges. In June 2007, information about the Collaborative was transferred to the Web site of RWJF's Improving Chronic Illness Care national program.

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Report prepared by: Kelsey Menehan
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Program Officer: Rosemary Gibson