PURPOSEWe investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing selfdirected (SD) practices with model information and resources, without facilitation. METHODSWe conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTSAlthough measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.CONCLUSIONS Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture. INTRODUCTIONT o meet the challenges of a reformed health care system, primary care must adopt substantially new models such as the PatientCentered Medical Home (PCMH) and integrate their work within accountable care organizations. [1][2][3][4] The PCMH has emerged as a cornerstone of primary care redesign with its strong appeal of uniting 4 compelling areas of health care reform: (1) the well-demonstrated value of primary care based on 4 core attributes, [5][6] (2) proactive, population-based approaches to chronic care, (3) consumerism and patient-centered care, and (4) new health information technology. Much of the redesign effort has focused on implementing the Chronic Care Model,6,7 which has been associated with better health outcomes for patients with chronic conditions and, specifically, type 2 diabetes 8,9 ; however, data regarding adoption of this model's principles into primary care practices have been disappointing. 10,11 Primary care practices have few mechanisms for incorporating new programs, which can slow adoption of innovations and cause disruptions when innovations are finally implemented. [12][13][14][15][16] With the central importance of primary care in health care redesign models such as the PCMH and accountable care organizations, effective strategies for enhancing primary care practice improvement...

The Colorado Multipayer Patient-Centered Medical Home Pilot, which ran from May 2009 through April 2012, was one of the first voluntary multipayer medical home pilot projects in the country. Six health plans, the state's high-risk pool carrier, and sixteen family or internal medicine practices with approximately 100,000 patients participated. Although a full analysis is currently under way, preliminary results show that the pilot significantly reduced emergency department visits and also reduced hospital admissions, particularly for patients with multiple chronic conditions. One payer reported a return on its investment of 250-400 percent in the pilot. However, participants also ran into numerous obstacles. Among them: Many practices were left providing extra services to a large fraction of patients whose employer-sponsored insurance plans declined to pay the enhanced fees necessary to cover the cost of the patient-centered medical home expansion. The experience demonstrates that creating patient-centered medical homes and enabling them to be successful will take strong commitments and collaborative efforts on multiple fronts.

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Cardiovascular disease (CVD) is the leading cause of death in the United States and is often attributable to poorly controlled yet modifiable risk factors. All national guidelines strongly recommend performing global CVD risk assessments to inform therapeutic intensity, but only a minority of clinicians regularly quantitate their patient's CVD risk. Not surprisingly, many patients are not at goal with regard to blood pressure, lipids, and the appropriate receipt of antiplatelet therapy. Given this background, the Colorado Clinical Guidelines Committee partnered with the Colorado Prevention Center to craft a simple algorithm for CVD risk reduction that emphasizes risk quantification and aggressive treatment for established CVD. The Colorado Clinical Guidelines Committee assembled a multidisciplinary team of health professionals with the goal of creating a comprehensive primary and secondary prevention framework that targets primary care physicians. We described the rationale, methods, and ultimate deployment of this guideline statewide in Colorado and hope this process may be a resource to other states interested in harmonizing a public health approach to CVD risk reduction.