Challenges of Change: A Qualitative Study of Chronic Care Model Implementation

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