Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

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...

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices. METHODSThe RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.RESULTS Primary care clinicians reported broad appreciation of the benefi ts of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specifi c attention was given to negotiating communication strategies with a clinician.CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption. Ann Fam Med 2008;6:30-37. DOI: 10.1370/afm.742. INTRODUCTION Depression is a common condition in primary care practice, 1,2 with a prevalence of 5% to 9%.1 Despite a solid evidence base for enhanced primary care of depression, [3][4][5][6][7][8][9][10][11] substantial defi cits in the adequacy of care remain. A principal component of evidence-based approaches to improving depression outcomes in primary care includes care management. 12 Although there is considerable evidence for its effectiveness in improving depression outcomes in a variety of primary care settings, [13][14][15][16] primary care clinicians have been slow to adopt care management. [17][18][19] Care management for depression consists of a combination of assessing and monitoring a patient's depression status; determining preferences, barriers, and progress; providing patient education and development of treatment and self-management plans; coordinating care with primary 18 lack of critical mass and fl exibility to assign care management roles, 19 and physician belief that depression is diffi cult to treat and of lower priority than...

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.