Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center

Health outcomes measurement and organizational readiness support quality improvement: a systematic review

“…Table 1 presents the characteristics of the 21 included studies. The studies focused on registries for the following patient groups; patients with diabetes [24–31], children with chronic conditions [32], patients with lung cancer [33, 34], patients with cystic fibrosis [35–37], patients with cardiac anomalies [38], patients undergoing cardiac surgery [39–41], patients with acute myocardial infarction [42], and patients referred for home health services [43]. The majority of the registries presented voluntary participation [25–27, 29–31, 35, 36, 38, 40–43].…”

“…Results were reported periodically and submitted to realize auditing on an annual basis.2-year survival+5-year survival+Siracusaet al, (2014) [37]Median FEV10 a 13Plan-do-check-act (PDCA)The Chronic Care ModelSeveral improvement interventions implemented between 2001 and 2007 with focus on patient and family engagement in CF care, improve access and use of data, individualized scheduling, improving vaccination rates, infection control aiway clearance, standardization of care processes, and forming and QI team.Median body mass index (BMI)0 a Peterson et al, (2015) [26]Systolic blood pressure0 a 13Plan-do-check-act (PDCA)Collaborative Care ModelThe effect of 23 diabetes teams joining a quality collaborative on patient outcomes.HbA1c0 a LDL0 a Han et al (2016) [31]Hospitalization with ambulatory care-sensitive conditions+7No clear QI methodUsing clinical registry data to identify patients who should receive reminders for preventive/follow-up care and send reminders to those patients. Generate a list of patients by condition to use for quality improvement.ED visits+Lail et al, (2017) [32]Disease remission0 a 13The Chronic Care ModelEighteen condition teams implemented interventions varying from: establishing pre-visit planning (PVP), identifying the target populations, selecting and measuring outcomes and supporting processes, building and implementing care coordination, and assessing and addressing self-management support. The teams were free to choose the interventions that they thought would work best.Disease control0 a Quality of life0 a Symptom management0 a 1 + means that the result was statistically significant at a p -value of 0.05 2 0 means that there was no significant improvement in outcomes 3 0 a means that there was improvement, but significance was not tested or reported…”

Managing paediatric bleeding disorder patients undergoing surgical procedures: Leveraging the electronic medical record

“…As part of a larger CCHMC improvement initiative, an EMR‐based registry was developed for all bleeding disorder patients followed by the HTC. Within this general “haemophilia all bleeding disorder” registry, additional registries were developed for 3 types of bleeding disorders: haemophilia (includes only patients with haemophilia A, haemophilia B and rare factor deficiencies), VWD for von Willebrand disease and QPD for qualitative platelet disorders.…”

Quality Improvement Strategies for Population Management of Children With Medical Complexity

“…12 One staff member managed the patient registry by incorporating new patient entry and established patient exit from the clinic. After multiple iterations of the Excel list, EMR experts worked with team leaders to build a patient registry embedded in the EMR and on-demand electronic care gap reports 13 that were customized to align with CCC's periodicity schedules for WCC and CCM. Functionalities for electronic risk stratification, patient portal activation, care gap reporting, and care team identification were built into the registry to permit data retrieval to support daily care and population management.…”