Challenges to improving chronic disease care and training in residencies

Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada's annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used.

METHODS

A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site.

RESULTS

Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging (key individuals to participate in program implementation), design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead.

CONCLUSIONS

This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.

Experiences of Patient-Centered Medical Home Staff Team Members Working in Interprofessional Training Environments

BACKGROUND

Evidence is growing that interprofessional team-based models benefit providers, trainees, and patients, but less is understood about the experiences of staff who work beside trainees learning these models.

OBJECTIVE

To understand the experiences of staff in five VA training clinics participating in an interprofessional team-based learning initiative.

DESIGN

Individual semi-structured interviews with staff were conducted during site visits, qualitatively coded, and analyzed for themes across sites and participant groups.

PARTICIPANTS

Patient-centered medical home (PCMH) staff members (n = 32; RNs, Clinical and Clerical Associates) in non-primary care provider (PCP) roles working on teams with trainees from medicine, nursing, pharmacy, and psychology.

APPROACH

Benefits and challenges of working in an interprofessional, academic clinic were coded by the primary author using a hybrid inductive/directed thematic analytic approach, with review and iterative theme development by the interprofessional author team.

KEY RESULTS

Efforts to improve interprofessional collaboration among trainees and providers, such as increased shared leadership, have positive spillover effects for PCMH staff members. These staff members perceive themselves playing an educational role for trainees that is not always acknowledged. Playing this role, learning from the "fresh" knowledge imparted by trainees, and contributing to the future of health care all bring satisfaction to staff members. Some constraints exist for full participation in the educational efforts of the clinic.

CONCLUSIONS

Increased recognition of and expanded support for PCMH staff members to participate in educational endeavors is essential as interprofessional training clinics grow.

Residents' Perspectives on Rewards and Challenges of Caring for Ambulatory Care Patients Living With Chronic Illness: Findings From Three Academic Health Centers

PURPOSE

To elicit residents' perspectives on rewards and challenges of caring for ambulatory patients with chronic illness and ways to improve their education in caring for these patients.

METHOD

The authors conducted a qualitative study with internal medicine residents during ambulatory medicine block rotations at three academic health centers from October 2011 through February 2012. Focus group questions covered rewards and challenges of caring for patients with chronic illness and strengths and weaknesses of residency education therein, and the Chronic Care Model provided a framework for interpretation. Qualitative analysis was used to identify themes.

RESULTS

Five focus groups were conducted with 28 residents. Discussions yielded 224 comments, which were categorized into 5 domains and 36 themes. Twelve themes related to perceptions of challenges in providing care, and 3 themes related to perceptions of rewards in providing care. Eight themes focused on strategies to improve the patient experience. Strengths of the residency program were identified in 7 themes. Six themes related to ways for improving learning about caring for patients with chronic disease in the ambulatory setting.

CONCLUSIONS

Residents perceived rewards, challenges, and barriers in caring for patients with chronic illness in the ambulatory setting, from providers' and patients' perspectives. They have developed strategies to provide effective patient care. Residents identified best practices in their residency for resident education and patient care and also made suggestions for improvement. Findings have significant implications for residency education and practice redesign in the 21st century for care of patients with chronic illness.

Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care

PURPOSE

To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.

METHOD

A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.

RESULTS

A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.

CONCLUSIONS

The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

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.

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.

Chronic care education in medical school: a focus on functional health and quality of life

The healthcare system is faced with a rapidly increasing number of individuals with chronic conditions and disabilities. The need for a chronic care model of health care with interdisciplinary treatment involving the patient and family with a focus on functional health is recognized but not fully established in the medical community. The education of medical students in a chronic care model is essential so that physicians in all specialties may provide effective and efficient care to their patients. Physiatrists and physicians trained in the specialty of Physical Medicine and Rehabilitation are uniquely situated to be leaders in the education of medical students in the appropriate care for individuals with chronic conditions and disabilities. Academic physiatrists must be involved in the education of medical students. This involvement will result in a higher level of patient care for all patients with chronic conditions and disabilities. In 2007, the Association of Academic Physiatrists formed a task force to evaluate educational models and make recommendations regarding the education of medical students in the management of individuals with chronic conditions and disabilities. The task force also evaluated opportunities for physiatrists to participate in the education of medical students. This article summarizes the work of the task force.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices

BACKGROUND

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.

OBJECTIVE

To improve training for residents who provide chronic illness care in teaching practice settings.

DESIGN

US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.

PARTICIPANTS

Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.

INTERVENTIONS

Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.

RESULTS

Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.

CONCLUSIONS

These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Using the Teamlet Model to improve chronic care in an academic primary care practice

BACKGROUND

Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.

OBJECTIVES

To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.

DESIGN

Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.

PARTICIPANTS

First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.

INTERVENTION

Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.

MEASUREMENTS

Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.

RESULTS

Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).

CONCLUSIONS

The Teamlet Model may improve chronic care in academic primary care practices.

Implementation of a chronic illness model for diabetes care in a family medicine residency program

INTRODUCTION

While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.

AIM

Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.

SETTING

University-affiliated, community-based family medicine residency program.

PROGRAM DESCRIPTION

Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.

PROGRAM EVALUATION

We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.

DISCUSSION

Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.

Experiential learning of systems-based practice: a hands-on experience for first-year medical residents

Systems-based practice, a domain of expertise mandated for all residencies by the Accreditation Council for Graduate Medical Education, requires an interdisciplinary approach that involves communicating with the other members of the health care team as well as utilizing the many components of health care delivery. The Mercy Catholic Medical Center internal medicine residency leadership developed a two-week supervised experience in systems-based practice for first-year medical residents to give them firsthand experience with nonphysician providers' delivery of health care. The disciplines in the experience were home care services, hospice care, pharmacy services, laboratory services, utilization services, and nutrition services. Nonphysician health care providers willingly made themselves available for this educational activity because they felt that such face-to-face interaction fosters an improved understanding of their discipline and its services in the participating physicians. Surveys of resident knowledge pre- and postworkshop suggested that the residents' rudimentary understanding of these disciplines developed into both a deeper theoretical understanding and a greater knowledge of specific policies regarding these health care services. This type of experience is likely a necessary first step toward developing physicians who can provide interdisciplinary medical care that integrates the many other health care disciplines into a comprehensive plan to maximize health outcomes. As physicians become leaders of multidisciplinary teams in the 21st century, firsthand knowledge of the other health services enhances their capacity to maximize the services of these other disciplines for the benefit of patient care.

Chronic disease management: time for consultant physicians to take more leadership in system redesign

There is a need for system redesign to meet the needs of individuals with chronic disease. New models of chronic disease care include team-based paradigms that focus on continuous and patient-centred care. In such models the roles of providers and patients must change. In this article we focus on new roles for consultant physicians, as well as barriers and incentives to these roles.

Transform residency training in chronic illness care -- now

Identification of the drivers of change that hasten improvement of chronic illness care in resident practices serves as an effective strategy for transformative change. The Academic Chronic Care Collaborative (ACCC) is an ongoing network of 48 teams from 22 teaching hospitals and systems that have committed to implementation of the evidence-based Chronic Care Model in their residency practices. The teams track the results of their efforts by monthly reports of both clinical and educational outcomes. The authors' experience with these self-selected teams shows that the two most effective drivers of change have been organization-wide leadership -- from the CEO to the clinical manager -- and the academic culture, e.g., competitiveness, the aspiration for excellence, focus on the research mission, comfort with data, and commitment to the education mission. These ACCC teams and their sponsoring health systems have successfully harnessed these drivers for the implementation of evidence-based chronic illness care in resident practices.