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
1RAND
2School
Health
of Public Health, UC Berkeley
3National
Center for Health Statistics
June 7, 2004
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-2 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-3 June 7, 04
Participating Organizations
Collaborative
Disease
National 1 National 2
Diabetes
5
CHF
10
Regional
Total
9
14*
10
Depression
6
6
Asthma
12
12
Total
15
18
9
42*
* One outlier
57% are single organization.
86% are providers (vs. plans).
45% are publicly-funded.
67% are outpatient providers.
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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)
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Continuation and Successful Spread
100%
Spread
80%
Expanded
60%
40%
20%
Collaborative
level
No spread
Decline
0%
Continuation
Spread
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Type of Spread
35%
30%
25%
20%
15%
10%
5%
Additional clinicians/
patients within site
Within & additional
sites
Additional sites
Additional sites and
other diseases
Within site, additional
sites, & other diseases
Within site & other
diseases
Other diseases
0%
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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
Depth
CCM 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)
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A Model for Chronic Illness Care
Health System Organization
Leadership commitment to quality
Self-Management
Support
Delivery System
Design
Skilled clinical educators Nurse case manager
Psychosocial support
Planned follow-up
Change plans
Decision
Support
Clinical Information
Systems
Feedback
Guidelines
Consultation
Registry
Reminders
Measurement
+ Links to Community Resources
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
Better Functional and Clinical Outcomes
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QI Sustainability and CCM Implementation
Bivariate Correlations with Quantity and Depth of CCM Implementation
Health System Organization
0.43**
Self-Management
Support
0.30†
0.28†
Delivery System
Design
0.36* 0.25
0.57**
Decision
Support
Clinical Information
Systems
0.56** 0.37*
0.35* 0.34*
Add'l sites
+ Links to Community
Resources
0.12
†
P < .10
Quantity of
Implementation
0.51**
0.18
Depth of
Implementation
0.47**
* P < .05
** p < .01
Greater Continuation of
Chronic Care Improvement
Shinyi Wu-10 June 7, 04
QI Spread and CCM Implementation
Bivariate Correlations with Quantity and Depth of CCM Implementation
Health System Organization
0.43**
Self-Management
Support
0.32* 0.29†
Delivery System
Design
0.22
0.11
0.37*
Decision
Support
Clinical Information
Systems
0.40** 0.38*
0.23 0.30†
Add'l sites
+ Links to Community
Resources
0. 01
†
P < .10
Quantity of
Implementation
0.40*
- 0.05
Depth of
Implementation
0.35*
* P < .05
** p < .01
Greater Success in Spreading
Chronic Care Improvement
Shinyi Wu-11 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
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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
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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.
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Influence of Disease Focus on Sustainability
Count of organizations
10
9
8
Decline
Collaborative level
Expanded
7
6
5
4
Chi-square test p <.05
3
2
1
0
Diabetes
CHF
Depression
Asthma
Shinyi Wu-16 June 7, 04
Influence of Disease Focus on Spread
Count of organizations
12
10
No spread
Spread
8
6
4
Chi-square test p <.05
2
0
Diabetes
CHF
Depression
Asthma
Shinyi Wu-17 June 7, 04