Sustainability and Spread of Chronic Illness Care Improvement Shinyi Wu 1 M. L. Pearson 1, S. M. Shortell 2, P. J. Mendel 1, J. A. Marsteller 3, M. K. Lin 2 E. B. Keeler 1 June 7, RAND Health 2 School of Public Health, UC Berkeley 3 National 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: improvingchroniccare.org ICICE: –Evaluation of QI effectiveness see: 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 1National 2RegionalTotal Diabetes5914* CHF10 Depression66 Asthma12 Total * 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 Expanded Collaborative level Decline Spread No spread

Shinyi Wu-7 June 7, 04 Type of Spread

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 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)

Shinyi Wu-9 June 7, 04 A Model for Chronic Illness Care Informed, Activated Patient ProductiveInteractionsProductiveInteractions Prepared Practice Team Better Functional and Clinical Outcomes Delivery System Design Nurse case manager Planned follow-up Decision Support Feedback Guidelines Consultation Clinical Information Systems Registry Reminders Measurement Self-Management Support Skilled clinical educators Psychosocial support Change plans Health System Organization Leadership commitment to quality + Links to Community Resources

Shinyi Wu-10 June 7, 04 QI Sustainability and CCM Implementation Depth of Implementation 0.47** Greater Continuation of Chronic Care Improvement Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Organization + Links to Community Resources 0.43** 0.57** 0.30 † 0.28 † 0.36* ** 0.37*0.35* 0.34* Quantity of Implementation 0.51** Bivariate Correlations with Quantity and Depth of CCM Implementation † P <.10 * P <.05 ** p <.01

Shinyi Wu-11 June 7, 04 QI Spread and CCM Implementation Depth of Implementation 0.35* Greater Success in Spreading Chronic Care Improvement Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Organization + Links to Community Resources 0.43** 0.37* 0.32* 0.29 † ** 0.38* † Quantity of Implementation 0.40* Bivariate Correlations with Quantity and Depth of CCM Implementation † P <.10 * P <.05 ** p <.01

Shinyi Wu-12 June 7, 04 Critical Areas of CCM for Sustainability and Spread OverallDSDSMSDSCISLCRHS 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 CHF Asthma Chi-square test p <.05

Shinyi Wu-17 June 7, 04 Influence of Disease Focus on Spread CHF Asthma Chi-square test p <.05