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

Abstract

BACKGROUND: 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. OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN: 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 ≤130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked. PARTICIPANTS: 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. INTERVENTIONS: 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. RESULTS: 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. CONCLUSIONS: 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.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

“…The evidence from these diabetes self-management implementation studies supports the provision of self-management for people with diabetes as they show consistent improvement in process outcomes, 237 Many of these studies, however, are uncontrolled before-and-after studies with the inherent methodological limitations. The only cluster randomised trial, in the very specific context of including CHWs in multidisciplinary collaborative programmes for diabetes improvement, showed improved process outcomes (documented self-management goals) but no difference in clinical outcomes.…”

“…Five papers reporting three studies focused on T1DM, [251][252][253][254][255] eight focused on T2DM, [246][247][248][249][250]260,261,264 the remaining 15 included mixed populations. [237][238][239][240][241][242][243][244][245][256][257][258][259]262,263 Thirteen of the studies were conducted in the USA, [237][238][239][244][245][246][247][248][256][257][258][259]262 one in the UK, 240 three from Germany (in five papers), 251,[253][254][255]260 three from Austria, 250,…”

“…Rapid cycles of the PDSA cycle resulted in improved documentation of self-management goals, but only modest improvements in HbA 1c . 237 Authors highlighted the substantial effort required to redesign services, even in the context of a highly motivated US secondary care clinic. 237 Primarily patient education, with or without organisational changes…”

Primary Care and Primary Care Training: Mirror Images

“…The national Academic/California Chronic Care Collaboratives showed that systematic practice and education redesign is achievable across disparate resident continuity clinics. 13 To their delight, researchers found teams that achieved better outcomes on clinical indicators reported more professional work satisfaction. 14 These papers point out an important first step in developing a transformed practicethe leaders of the practice must seek training in improvement techniques and be able to bring these concepts home to their institutions.…”

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

“…[15][16][17][18][19][20] Early residency education redesign initiatives, including the Academic Chronic Care Collaborative, 21,22 Health Resources and Services Administration (HRSA) efforts, 23 and Veterans Affairs Centers of Excellence in Primary Care Education, are significant investments. 24 However, most residents still train in poorly organized practices, with few, if any, PCMH elements.…”