Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings

INTRODUCTION

With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings.

METHODS

A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance.

RESULTS

Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level.

CONCLUSION

IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

Reducing Treatment Burden Among People With Chronic Conditions Using Machine Learning: Viewpoint

The COVID-19 pandemic has illuminated multiple challenges within the health care system and is unique to those living with chronic conditions. Recent advances in digital health technologies (eHealth) present opportunities to improve quality of care, self-management, and decision-making support to reduce treatment burden and the risk of chronic condition management burnout. There are limited available eHealth models that can adequately describe how this can be carried out. In this paper, we define treatment burden and the related risk of affective burnout; assess how an eHealth enhanced Chronic Care Model can help prioritize digital health solutions; and describe an emerging machine learning model as one example aimed to alleviate treatment burden and burnout risk. We propose that eHealth-driven machine learning models can be a disruptive change to optimally support persons living with chronic conditions.

The who, the what, and the how: A description of strategies and lessons learned to expand access to medications for opioid use disorder in rural America

Access to treatment for opioid use disorder (OUD) in rural areas within the United States remains a challenge. Providers must complete 8-24 h of training to obtain the Drug Addiction Treatment Act (DATA) 2000 waiver to have the legal authority to prescribe buprenorphine for OUD. Over the last 4 years, we executed five dissemination and implementation grants funded by the Agency for Healthcare Research and Quality to study and address barriers to providing Medications for Opioid Use Disorder Treatment (MOUD), including psychosocial supports, in rural primary care practices in different states. We found that obtaining the DATA 2000 waiver is just one component of meaningful treatment using MOUD, and that the waiver provides a one-time benchmark that often does not address other significant barriers that providers face daily. In this commentary, we summarize our initiatives and the common lessons learned across our grants and offer recommendations on how primary care providers can be better supported to expand access to MOUD in rural America.

A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review

BACKGROUND

Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting.

OBJECTIVE

We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine.

METHODS

The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed.

RESULTS

A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes.

CONCLUSIONS

While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.

Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review

BACKGROUND

Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease.

METHOD AND RESULTS

This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation.

CONCLUSION

This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum

BACKGROUND

Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs.

OBJECTIVE

We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum.

METHODS

From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group.

RESULTS

Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41).

CONCLUSIONS

The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.

Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System

Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.

Factors influencing the implementation of chronic care models: A systematic literature review

Background

The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels.

Methods

The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013.

Results

The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes.

Conclusion

This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0319-5) contains supplementary material, which is available to authorized users.

Utilizing the Ipswich Touch Test to simplify screening methods for identifying the risk of foot ulceration among diabetics: The Saudi experience

Our study demonstrates that Ipswich Touch Test is reliable and comparable to established standardized tests that identify the risk of foot ulceration among Saudi patients with diabetes mellitus. The simplicity of the test will assist in overcoming the barriers to screen for and detect the risk of foot ulceration.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Chronic care model as a framework to improve diabetes care at an academic internal medicine faculty-resident practice

We implemented a quality improvement project for diabetes care in a faculty-resident internal medicine practice, using the Chronic Care Model framework. We created a planned visit clinic, used a stepwise medication algorithm, and self-management support. The intervention was effective for patients with glycohemoglobin A1c levels 10 or above (P = .0075) when compared with usual care after adjusting for all significant predictors. Compliance with foot examinations increased by 72% (P < .0001) and pneumococcal vaccinations by 25% (P = .0115). We believe that the Chronic Care Model can be successfully integrated into faculty-resident practices and provides a model for further exploration into disease management education in academic settings.

What is the role of general internists in the tertiary or academic setting?

The changing demography of European populations mandates a vital role for internists in caring for patients in each level of healthcare. Internists in the tertiary or academic setting are highly ranked in terms of their responsibilities: they are clinicians, educators, researchers, role models, mentors and administrators. Contrary to the highly focused approach of sub-specialties, general internists working in academic settings can ensure that coordinated care is delivered in the most cost-conscious and efficient way. Moreover, internal medicine is one of the most appropriate specialties in which to teach clinical reasoning skills, decision-making and analytical thinking, as well as evidence based, patient oriented medicine. Internists deal with challenging patients of the new millennium with a high burden of chronic diseases and polypharmacy; practice personalised medicine with a wide scientific background and so they are the perfect fit to establish and implement new tools for scientific research. In conclusion, internal medicine is developing a new identity as a specialty in its own right. The European Federation of Internal Medicine supports the concept of academic internists and calls upon the member countries to construct academic (general) internal medicine departments in their respective countries. As 'internal medicine is the cornerstone of every national healthcare system', academic (general) internal medicine should strive to be the cornerstone of every integrated, patient-centred, modern medical care and training system.

More extensive implementation of the chronic care model is associated with better lipid control in diabetes

OBJECTIVE

Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes.

METHODS

We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL.

RESULTS

Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher "registry" and "protocol" KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant.

CONCLUSIONS

Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.

Effect of a multidisciplinary-assisted resident diabetes clinic on resident knowledge and patient outcomes

BACKGROUND

Despite the rising prevalence of diabetes, there is a paucity of diabetes curricula in residency training. The multidisciplinary diabetes team approach is underused in residency education.

OBJECTIVE

To assess the feasibility of an innovative multidisciplinary resident diabetes clinic (MRDC) in enhancing (1) resident diabetes knowledge via a Diabetes Awareness Questionnaire, and (2) subsequent process and patient outcomes in patients with diabetes via a Diabetes Practice Behavior Checklist.

METHODS

From October 2008 to February 2010, 14 internal medicine residents managed patients with uncontrolled diabetes in a weekly half-day MRDC for 1 month (total 4-5 half-day sessions/resident), with a collaborative team of internists, diabetes educators, an endocrinologist, and a pharmacist. The curriculum included didactic sessions, required readings, and patient-specific case discussions. A 20-question Diabetes Awareness Questionnaire was administered to each resident prerotation and postrotation. Records of 47 patients with diabetes in the residents' own continuity clinics (not the MRDC) were audited 6 months before and after the MRDC for Diabetes Practice Behavior Checklist measures (glycated hemoglobin, blood pressure, low-density lipoprotein cholesterol, retinal referral, foot exam, microalbumin screen). Pre-MRDC and post-MRDC data were compared via paired t test.

RESULTS

The MRDC residents exhibited a modest increase in mean (SD) scores on the Diabetes Awareness Questionnaire (before, 8.2 [2.8]; after, 10.9 [2.8]; P  =  .02) and a modest mean (SD) performance increase in overall process outcomes from the Diabetes Practice Behavior Checklist (before, 74% [18%]; after, 84% [18%]; P  =  .004). No improvements occurred in patient outcomes.

CONCLUSIONS

Multidisciplinary diabetes teaching may be useful in fostering certain resident knowledge and performance measures but may not alter clinical outcomes. Further large-scale, longitudinal studies are needed to understand the effect of our curriculum on residents' diabetes knowledge and future practice behavior.

An Application of a New Evidence Grading System to Research on the Chronic Care Model

Methodological quality undergirds all evidence-based medicine because without strong evidence supporting or refuting the efficacy of an intervention, the movement toward basing medical decisions and practice on scientific evidence is not sustainable. Recently, the consensus that had existed regarding the hierarchy of evidence produced by a study design was challenged on the basis that existing guidelines failed to properly define key terms, weight the merits of certain non-randomized controlled trials, and employ a comprehensive list of study design limitations to render evaluative conclusions, to name a few of the challenges. The present study introduces a new grading system that overcomes, or at the very least greatly diminishes, these challenges. This new method is applied to the literature on the Chronic Care Model and the results are then compared to several of the most popular grading guidelines currently in use. These results revealed substantial differences between the guidelines in accordance with previous research that challenged existing methods. Furthermore, the present study lends support to the proposed grading guideline although further research into its validity and reliability is needed.

Physicians' perceptions of the type 2 diabetes multi-disciplinary treatment team: a qualitative study

PURPOSE

The purpose of this study was to explore physicians' perceptions of the multidisciplinary type 2 diabetes treatment team.

METHODS

Nineteen physicians (74% endocrinologists; 26% primary care) participated in semistructured interviews. Audiorecorded data were transcribed, coded, and analyzed using thematic analysis and NVivo 8 software.

RESULTS

Physicians considered the multidisciplinary team, including a physician and diabetes educator, as very important to diabetes treatment. Participants described how diabetes, with its many comorbidities and challenging lifestyle recommendations, is difficult for any single physician to treat. They further described how the team's diverse staff offers complementary skills and more contact time for assessment and treatment of patients, developing treatment relationships, and supporting patients in learning diabetes self-care. Physicians stressed the necessity of regular and ongoing communication among team members to ensure patients receive consistent information, and some reported that institutional factors interfere with intra-team communication. They also expressed concerns about the team approach in relation to individualized treatment and patients' reluctance to see multiple providers.

CONCLUSIONS

This study highlights physicians' positive perceptions of and concerns about the type 2 diabetes multidisciplinary team. Further study of diabetes educators' and patients' perceptions of the team approach is needed.

Improving care in a resident practice for patients with diabetes

BACKGROUND

Curricular redesign and introduction of the Chronic Care Model in our residency clinic during 2005-2007 achieved limited success in glycemic (glycated hemoglobin level [A(1c)]), lipid (low-density lipoprotein fraction [LDL]), and blood pressure (BP) control for patients with diabetes.

INTERVENTION

Beginning in January 2008, ancillary staff performed previsit, protocol-driven reviews of medical records of patients with diabetes to identify those not at A(1c), LDL, and BP goals; inserted electronic prompts into the records regarding deficiencies; and obtained samples for A(1c) or lipid panel when needed. Faculty feedback regarding resident-specific panel reviews was added in May 2008, and point-of-care A(1c) testing was implemented in February 2009.

METHODS

We conducted a 2-year retrospective study of all patients at our facility with diabetes mellitus, who had at least 1 visit during January to June 2008 (baseline) and 1 visit during July to December 2009 (follow-up). Measures included the most current A(1c), LDL, and BP results. Paired outcome results were compared using the McNemar χ(2) test.

RESULTS

A total of 522 patients with diabetes mellitus were seen during the baseline and follow-up periods, and 456 patients (87.4%) had paired A(1c) results, with A(1c) < 7.0% for 138 of 456 patients (30.3%) at baseline and 166 of 456 patients (36.4%) at follow-up (P  =  .011). For LDL, 460 patients (88.1%) had paired results, with LDL < 100 mg/dL for 225 of 460 patients (48.9%) at baseline and 262 of 460 patients (57.0%) at follow-up (P  =  .004). A total of 513 patients (98.3%) had paired BP results in which the BP < 130/80 mm Hg for 124 of 513 patients (24.2%) at baseline and for 188 of 513 patients (36.6%) at follow-up (P < .001). There were 421 patients (80.7%) with paired results for all 3 measures, with 17 of 421 patients (4.0%) at goal at baseline and 41 of 421 patients (9.7%) at goal at follow-up (P  =  .001).

CONCLUSION

The interventions resulted in statistically significant improvements in the proportion of patients with diabetes who attained goal for A(1c), LDL, and BP levels. Our redesign elements may be useful in enhancing resident education and in improving patient care.

Assessing Chronic Illness Care Education (ACIC-E): a tool for tracking educational re-design for improving chronic care education

BACKGROUND

Recent Breakthrough Series Collaboratives have focused on improving chronic illness care, but few have included academic practices, and none have specifically targeted residency education in parallel with improving clinical care. Tools are available for assessing progress with clinical improvements, but no similar instruments have been developed for monitoring educational improvements for chronic care education.

AIM

To design a survey to assist teaching practices with identifying curricular gaps in chronic care education and monitor efforts to address those gaps.

METHODS

During a national academic chronic care collaborative, we used an iterative method to develop and pilot test a survey instrument modeled after the Assessing Chronic Illness Care (ACIC). We implemented this instrument, the ACIC-Education, in a second collaborative and assessed the relationship of survey results with reported educational measures.

PARTICIPANTS

A combined 57 self-selected teams from 37 teaching hospitals enrolled in one of two collaboratives.

ANALYSIS

We used descriptive statistics to report mean ACIC-E scores and educational measurement results, and Pearson's test for correlation between the final ACIC-E score and reported educational measures.

RESULTS

A total of 29 teams from the national collaborative and 15 teams from the second collaborative in California completed the final ACIC-E. The instrument measured progress on all sub-scales of the Chronic Care Model. Fourteen California teams (70%) reported using two to six education measures (mean 4.3). The relationship between the final survey results and the number of educational measures reported was weak (R(2) = 0.06, p = 0.376), but improved when a single outlier was removed (R(2) = 0.37, p = 0.022).

CONCLUSIONS

The ACIC-E instrument proved feasible to complete. Participating teams, on average, recorded modest improvement in all areas measured by the instrument over the duration of the collaboratives. The relationship between the final ACIC-E score and the number of educational measures was weak. Further research on its utility and validity is required.

Academia, chronic care, and the future of primary care

Most proposals to reform health care delivery center on a robust, well-designed primary care sector capable of reducing the health and cost consequences of major chronic illnesses. Ironically, the intensified policy interest in primary care coincides with a steep decline in the proportion of medical students choosing primary care careers. Negativity stemming from the experience of trying to care for chronically ill patients with complex conditions in poorly designed, chaotic primary care teaching settings may be influencing trainees to choose other career paths. Redesigning teaching clinics so that they routinely provide high quality, well-organized chronic care would appear to be a critical early step in addressing the looming primary care workforce crisis. The Chronic Care Model provides a proven framework for such a redesign, and has been, with organizational support and effort, successfully implemented in academic settings.

Developing measures of educational change for academic health care teams implementing the chronic care model in teaching practices

BACKGROUND

The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents' competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.

SUBJECTS

Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.

METHOD

Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs' abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.

ANALYSIS

Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.

RESULTS

Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.

CONCLUSION

Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.