Sustainability and Spread of Chronic Illness Care Improvement

Shinyi Wu1 (shinyi@rand.org)M. L. Pearson1, S. M. Shortell2, P. J. Mendel1,

J. A. Marsteller3, M. K. Lin2 E. B. Keeler1

June 7, 2004

1RAND Health2School of Public Health, UC Berkeley

3National Center for Health Statistics

Shinyi Wu-2 June 7, 04

Chronic Care Model Collaborative

• CCM/IHI Collaboratives:– Multi-faceted interventions to improve systems

of care as well as individual provider behavior• see: http:// improvingchroniccare.org

• ICICE:– Evaluation of QI effectiveness

• see: http://www.rand.org/health/ICICE

• Funded by the RWJF

Shinyi Wu-3 June 7, 04

Quality Improvement: Built to Last?

• Objectives of the study– To assess the sustainability and spread of CCM

implementation efforts– To examine their relationships with CCM

implementation intensity

Shinyi Wu-4 June 7, 04

Participating Organizations

Collaborative Disease

National 1 National 2 Regional Total

Diabetes 5 9 14*

CHF 10 10

Depression 6 6

Asthma 12 12

Total 15 18 9 42*

57% are single organization.

45% are publicly-funded.86% are providers (vs. plans).

67% are outpatient providers.

* One outlier

Shinyi Wu-5 June 7, 04

Measures of Sustainability and Spread• Data sources

– Telephone interviews with key informant(s)– Coded monthly reports and meeting materials submitted by the organizations

• Measures– Sustainability: post-collaborative status of the QI activities

• Expanded (coded as 2)• Maintained at collaborative level only (1)• Declined or drifted (0)

– Spread: self-reported success at spread• Any (Yes or no, coded as 1 and 0)• Type (7 categories of spread)

Shinyi Wu-6 June 7, 04

Continuation and Successful Spread

0%

20%

40%

60%

80%

100%

Continuation Spread

Expanded

Collaborative level

Decline

Spread

No spread

Shinyi Wu-7 June 7, 04

Type of Spread

0%

5%

10%

15%

20%

25%

30%

35% Additional clinicians/patients within siteWithin & additionalsitesAdditional sites

Additional sites andother diseasesWithin site, additionalsites, & other diseasesWithin site & otherdiseasesOther diseases

Shinyi Wu-8 June 7, 04

Analysis of Relationships with Implementation• Bivariate correlations• Ordinal regressions :1) Sustainability 2) Spread

– Controlled for disease.– Each independent variable is fitted separately.

Independent variables*

Quantity DepthCCM overall

Delivery system design (DSD)Self-management support (SMS)

Decision support (DS)Clinical Information systems (CIS)

Links to community resources (LCR)Health system organization (HS)

Shinyi Wu-9 June 7, 04

A Model for Chronic Illness Care

Informed,Activated

Patient

ProductiveProductiveInteractionsInteractions

PreparedPractice

Team

Better Functional and Clinical Outcomes

Delivery SystemDesign

Nurse case managerPlanned follow-up

DecisionSupport

FeedbackGuidelines

Consultation

Clinical InformationSystemsRegistry

RemindersMeasurement

Self-Management Support

Skilled clinical educatorsPsychosocial support

Change plans

Health System OrganizationLeadership commitment to quality

+ Links to Community Resources

Shinyi Wu-10 June 7, 04

QI Sustainability and CCM Implementation

Add'l sites

Depth ofImplementation

0.47**

Greater Continuation of Chronic Care Improvement

Delivery SystemDesign

DecisionSupport

Clinical InformationSystems

Self-Management Support

Health System Organization

+ Links to Community Resources

0.43** 0.57**

0.30† 0.28† 0.36* 0.25 0.56** 0.37* 0.35* 0.34*

Quantity of Implementation

0.51**

Bivariate Correlations with Quantity and Depth of CCM Implementation

0.12 0.18

† P < .10

* P < .05

** p < .01

Shinyi Wu-11 June 7, 04

QI Spread and CCM Implementation

Add'l sites

Depth ofImplementation

0.35*

Greater Success in Spreading Chronic Care Improvement

Delivery SystemDesign

DecisionSupport

Clinical InformationSystems

Self-Management Support

Health System Organization

+ Links to Community Resources

0.43** 0.37*

0.32* 0.29† 0.22 0.11 0.40** 0.38* 0.23 0.30†

Quantity of Implementation

0.40*

Bivariate Correlations with Quantity and Depth of CCM Implementation

0. 01 - 0.05

† P < .10

* P < .05

** p < .01

Shinyi Wu-12 June 7, 04

Critical Areas of CCM for Sustainability and Spread

Overall DSD SMS DS CIS LCR HS

Sustainability

Quantity

Depth

Spread

Quantity

Depth

Based on ordinal regressions. < .10 < .05 < .01

Shinyi Wu-13 June 7, 04

Summary

• One year later, most health organizations report sustaining and spreading the CCM change efforts.

• Keys to sustaining chronic care improvement and facilitating successful spread:

– Intensively implement CCM during the collaborative period

• Acquire health system support• Reorganize delivery system• Build clinical information system• Increase decision support capabilities• Provide self-management support

Shinyi Wu-14 June 7, 04

Implications for Quality Improvement

Chronic care improvement can be sustained after the intervention period and successfully spread to

other areas.

To sustain and spread CCM changes, collaborative and organizational leaders should promote change

efforts (in both quantity and depth) during the initial collaborative period.

Shinyi Wu-15 June 7, 04

Shinyi Wu-16 June 7, 04

Influence of Disease Focus on Sustainability

0123456789

10

Coun

t of o

rgan

izat

ions

Diabetes Depression

DeclineCollaborative levelExpanded

CHF Asthma

Chi-square test p <.05

Shinyi Wu-17 June 7, 04

Influence of Disease Focus on Spread

0

2

4

6

8

10

12

Coun

t of o

rgan

izat

ions

Diabetes Depression

No spreadSpread

CHF Asthma

Chi-square test p <.05