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Assessing the Implementation of the Chronic Care Model in Quality Improvement Collaboratives
Marjorie L. Pearson, Shinyi Wu, Judith Schaefer, Amy E. Bonomi, Stephen M. Shortell, Peter J. Mendel, Jill A. Marsteller, Thomas A. Louis, Mayde Rosen, Emmett B. Keeler, Health Services Research, [e-pub ahead of print], 2005.

Viewing the article requires registration or purchase at:
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1475-6773.2005.00397.x

A Technical Appendix (Methods) is also available:
http://www.rand.org/publications/WR/WR217/

Research Objective: To measure organizations' implementation of Chronic Care Model (CCM) interventions initiated during participation in chronic care quality improvement (QI) collaboratives.

Study Design: We qualitatively analyzed the implementation activities of intervention organizations as part of a larger effectiveness evaluation that utilized a before-and-after design with comparison sites. Key study variables included measures of implementation intensity (quantity and depth of implementation activities) as well as fidelity to the CCM. The CCM is an organizing framework for directing structural and process improvements in chronic care across six areas: self-management support, delivery system redesign, decision support, information support, community linkages, and health system support. Utilizing the CCM framework, we coded the activities reported by the organizations in monthly reports and telephone interviews. Within CCM categories, these activities were counted and qualitatively rated as to their depth or likelihood of impact (using predefined criteria) to create the implementation intensity measures. Variations in implementation intensity within CCM categories and among healthcare organizations were examined. The measures were compared to sites' pre- and post- intervention assessments of their practices' congruence with CCM.

Population Studied: Monthly reports submitted by 42 organizations participating in four QI collaboratives to improve care for congestive heart failure, diabetes, depression, or asthma, as well as telephone interviews conducted with key informants in the organizations.

Principal Findings: During the collaborative, the organizations made multiple, diverse changes to implement the CCM. The 42 organizations averaged more than 30 different change efforts each. The depth ratings for these changes, however, were more modest, ranging from 17 percent to 76 percent of the highest depth rating possible. The participating organizations significantly differed in the intensity of their implementation efforts (p<.001 in both quantity and depth ratings). Fidelity to the CCM was high; 98 percent of the organizations implemented changes in at least 5 of the 6 CCM areas and 81 percent did so in all 6 areas. Among CCM areas, most emphasis was placed on improving information system support and least on developing community linkages. Significant positive correlations were found between these measures of implementation performance and the pre-post differences in the sites' assessments of their systems conformance with CCM elements.

Conclusions: The findings suggest that collaborative participants were able, with some important variation, to implement large numbers of QI change strategies, with high CCM fidelity and modest depth of intensity.

Implications for Policy, Delivery, or Practice: Chronic care QI collaboratives can successfully encourage healthcare organizations to implement multiple, diverse changes to more closely align their systems with the CCM.