Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Abstract

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes

“…However, we were unable to locate any such published research. Existing literature typically finds positive clinical improvements comparing care management with usual care in carefully controlled settings, [8][9][10]13 in contrast to this study's real world implementation. Research on factors related to successful implementation of care management that leads to clinical improvement is limited.…”

“…However, the latter has the advantage of integration and coordination with the patient's PCP, which may be key to improving health outcomes. [8][9][10][11][12] Although each of the two aforementioned approaches has been evaluated independently, there is a lack of studies comparing them directly. In addition, the literature is inconsistent with regard to outcomes in natural care delivery settings.…”

Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT)

“…The review built on an existing evidence synthesis, prepared by the VA's EvidenceBased Synthesis Program Coordinating Center. 11 Researchers 14,16,18,[21][22][23][30][31][32][33] and with review articles describing healthcare delivery interventions for patients with complex chronic illnesses. [34][35][36] The review incorporated key findings, study design, and implementation strategies, 37 and was discussed with facility leadership to identify common elements of successful programs that would be viable and effective within the VA environment and at the local facility.…”

“…Methods and additional information about the study review process are described in Online Appendix 2. Dorr and colleagues 23 provide additional information on Intermountain Healthcare. 30 Lessler and colleagues 32 provide additional information on King County Care Partners.…”

“…Robust evaluations may require staged interventions or randomization, long follow-up duration, and patient and staff surveys to determine effects, adding cost and time beyond the already expensive clinical efforts. [21][22][23] Partnered research-collaboration between researchers, operational leaders, and clinicians-is a unique approach to program development that may facilitate rapid healthcare redesign and implementation, while allowing for rigorous evaluation and testing. The VA has a rich tradition of sponsoring intramural partnered research, dating back to the development of the Quality Enhancement Research Initiative in the 1990s, 24 and these partnerships have been associated with substantial quality improvement achievements.…”