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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The importance of patient-physician relation
Chronic Care Model:Perseverance and Patience Pay off
Flying While Designing the Plane: Implementing the CCM
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Stefano Alice, Genova (Italy) Family Physician
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The implementation of Chronic Care Model requires a well informed patient, which means a good patient-physician communication. I find very important to check if the patient really understands his disease anf if he has a good comprehension of my suggestions and directions. The greatest problem is that there isn't a good communication without a very good patient-physician relation. For instance, in my experience, standardized information has a very poor therapeutic efficacy. To care about chronics needs time and patience, but patience is the consequence of affection: here is the problem! Competing interests: None declared |
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Phil Mohler, Grand Junction CO Family Physician Family Physicians of Western Colorado
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Both these studies…Hroscikoski et al. and Solberg et al…. add significantly to the understanding of the barriers and frustrations of implementing the Chronic Care Model (CCM). There is an air of disappointment in their papers... that the CCM did not incite revolution of care processes, that the clinical outcomes were not more robust and that the physicians did not embrace the CCM more amorously. Our five- year experience with the CCM in managing 800 diabetics in a 15 family physician group mirrors many of their findings. 1) Our docs, like many physicians, were initially genetically resistant to change and needed an omnipresent physician champion to move the process along. 2) Gypsy Rose Lee was right. “You gotta have a gimmick" (or tool) Ours is a one-page emr generated color patient report that graphically displays patient weight, blood pressure, LDL, hemoglobin A1 C, albumin/ creatinine ratio, eye and foot exams and aspirin use-all over time. Our physicians love it! It makes their care more efficient and more complete. 3) The authors’ references to the time, staff and money barriers that abound in Chronic Care Model implementation certainly are accurate. Five years out, however, our physicians have embraced the model in willingly financially underwriting the “loss" the project generates (~$1500/year/doc) because it improves care and makes their(the docs) lives easier. Phil Mohler, MD Competing interests: None declared |
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Everett E Logue, PhD, Akron, OH Director, Family Medicine Research Center, Summa Health System
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This issue contains complementary quantitative and qualitative papers on a recent attempt to apply the Chronic Care Model (CCM) in primary care clinics affiliated with a large multi-specialty group.1,2 The quantitative paper examines associations between CCM implementation ratings in 17 clinics and standard measures of care quality for diabetes, CHD, and depression.1 The qualitative paper presents a concise narrative of what actually happened according to those who were involved.2 The quantitative paper shows that mean CCM implementation scores changed in the expected direction over two years, and that 5 of 8 mean quality of care measures also improved. However, (Pearson) correlations between CCM rating scores and the quality of care measures were modest and generally non- significant. Measurement issues and a small sample size could explain the modest or non-significant correlations. The qualitative paper and 20/20 hindsight reveals that the attempt to implement the CCM was not adequately designed, piloted, or fueled before it took off. Leadership was ambivalent. EMR implementation competed for attention with other process changes. PDSA tools were missing. Some key CCM components were largely ignored. Plans were vague. Staff was overloaded with change. ‘Rebuilding an airplane while it is flying’ is challenging work, particularly if your organization starts with a pencil sketch of the new design, an empty toolbox, and maxed out workers rather than a detailed blueprint, the right tools, and motivated colleagues. Experience implementing the CCM is available in the peer-reviewed literature, at the Improving Chronic Illness Care website, and in various national collaboratives.3-5 Primary care is complex. The pace and scale of the re-engineering effort will mirror this complexity, but the effort must be made. References 1. Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O’Connor PJ. Care quality and implementation of the chronic care model: A quantitative study. Ann Fam Med 2006;4:310-316 2. Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: A qualitative study of chronic care model implementation. Ann Fam Med 2006;4:317-326. 3. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic diseases. Am J Manag Care 2005;11(8):478-488. 4. Improving Chronic Illness Care. http://www.improvingchroniccare.org/ (accessed 7/21/2006) 5. Academic Chronic Care Collaborative. http://www.aamc.org/patientcare/iicc/initiatives.htm (accessed 7/21/2006) Competing interests: None declared |
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