Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

The Article in Brief

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

W. Perry Dickinson , and colleagues

Background Many practice redesign efforts focus on implementing the Chronic Care Model, which summarizes basic elements for improving care in health systems at the community, organization, practice and patient levels. The current study compares the effectiveness of three different Chronic Care Model-based approaches to improve diabetes care in primary care. The three approaches are 1) Continuous Quality Improvement (CQI) in which practices follow a strategy of implementing registries to have diabetes quality measures motivate practice action, identify needed changes, and monitor progress; 2) Reflective Adaptive Process (RAP) in which practices follow a more practice-determined approach for improving practice culture; and 3) Self-Directed (SD) in which practices are given information and resources about the Chronic Care Model and quality improvement but without the assistance of a facilitator.

What This Study Found All methods resulted in significant improvement in diabetes care measures, but there were differences in the extent and duration of improvement and trade-offs in work culture change. Although measures of the quality of diabetes care improved in all three groups, improvement was greater in CQI practices compared with both SD and RAP practices, and greater in SD practices compared with RAP practices. In RAP practices, change culture scores showed a trend toward improvement at nine months, but decreased below baseline at 18 months, and work culture scores decreased from nine to 18 months. Both scores were stable over time in SD and CQI practices.

Implications

• Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice culture.
• Short-term practice facilitation based on RAP principles appears to be less effective at improving quality measures and does not produce sustained improvements in practice culture.
• Recognizing that not all primary care practices need the same type, intensity, or duration of assistance, the authors call for practices to tailor the approach to their practice. They also call for the development and testing of new models that can produce the long-term improvements in both quality measures and practice cultures necessary for sustained care enhancement.