The Chronic Care Model: A fancy name for a team approach to patient care

1. The Chronic Care Model: A fancy name for a �team approach� to patient care Pam Allweiss MD, MPH (pca8@cdc.gov) Consultant CDC Division of Diabetes Translation Faculty: University of Kentucky

2. Chronic Conditions Affect an estimated 99 million Americans. Of these, 41 million people have their daily activities limited in some way 20 to their condition 12 million are unable to live independently. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others.

3. We Have an Epidemic of Diabetes!

5. The patient whom you saw yesterday 70 year old female, is the caregiver for a grandchild 15 yr history of diabetes, HTN, both poorly controlled She initiates her visits when she perceives a problem Confused about diet, exercise, meds Recent onset of CHF pain leading to hospitalization Greater confusion following discharge Readmitted in 1 week

6. The Patients� Current Care Experience  Patient initiated contacts oriented to acute problem Focus on symptoms and lab results, not longer term disease control and prevention No systematic attention to her knowledge, skills and behaviors in managing her illness Care not planned Care dependent on doctor, doctor�s memory, and disorganized written record Communication among providers not a priority

7. Would she have received different care in an academic medical center? Of CHF patients discharged from 7 university hospitals: 72% were discharged on an ACE inhibitor 44% received a recommended ACE inhibitor dose 11% had documented counseling about following daily weights 9% of smokers received documented counseling (2)

8. Why are we discussing this? Don�t shoot the messenger Learn about the theory for possible recertification Learn about the concepts to deal with managed care, Pay for performance Learn about the ideas to help out patients Evolution of how care is delivered

9. Future of Primary Care Medicine Learning modules for chronic disease Medical home for patient Better patient outcomes Pay for performance issues The business case for chronic disease management Annals of Family Medicine 2:S3-S32 (2004) A E

10. Barriers to Effective Chronic Disease Management Rushed practitioners not following established practice guidelines (according to surveys) Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses

11. What Patients with Chronic Illnesses Need Coordination of care across settings and professionals Systematic follow-up and assessment tailored to clinical severity A care team and practice system organized to meet their needs for Information and support for their self-management,

12. The IOM Quality report: A New Health System for the 21st Century �The current care systems cannot do the job.� �Trying harder will not work.� �Changing care systems will.� In 2001, the Institute of Medicine published this report. Usual care in US has been described in the recent IOM report, Crossing the Quality Chasm.In 2001, the Institute of Medicine published this report. Usual care in US has been described in the recent IOM report, Crossing the Quality Chasm.

13. What is the Chronic Care Model (CCM) and Why do we need It? Chronic conditions affect an estimated 99 million Americans. IOM report: quality improvement issue As a result, many managed care and have taken a great interest in correcting the many deficiencies in current management of chronic conditions CCM: Well established template to improve outcomes

14. If care were improved to the extent found in the literature�the Quality Chasm Most patients with chronic illness would have regular prevention and be on effective treatments Major risk factors (HbA1c, BP, LDL) would be significantly reduced Recovery rates for major depression would be nearly doubled Children with moderate asthma would be symptom-free two weeks less each year Risk of major diabetic complications would be reduced 20-50% Readmission rates of persons hospitalized with CHF would be reduced by about 25% and survival and quality of life improved

15. Better Models of Care Exist Adapting innovations from outside health care � innovations in information management, performance tracking, physical design, scheduling, communications, and so-called "lean production" � to the clinical office and outpatient settings.

16. Essential Elements Health provider support: must have buy in from providers (you can teach docs new ways of doing things!) Administrative support: The �top dogs� must live and breath the chronic care model All members of the clinic are part of the team: ALL employees, ALL patients

17. System Change ConceptsWhy a Chronic Care Model? Document of successful interventions What are common themes of interventions and barriers for ALL chronic conditions? Compliance, self management, access to meds and education How can system be improved to support above themes?

18. The Chronic Care Collaboratives: a transformation in the delivery of care. Transformation of health care Change from a system that is �reactive� (responding mainly when a person is sick) � to one that is �proactive� Chronic Care Model summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels.

19. The Chronic Care Collaboratives: a transformation in the delivery of care. providers such as doctors, dentists, social workers, and nurses deliver care: new attitude patients understand and participate in managing their own care; and communities learn to strengthen the provider-patient partnership. Sounds like Utopia! IHI, Institute for Health Care Improvement, Univ of Washington Improving Chronic Care RWJ support

20. Themes in the Chronic Care Model Evidence-based Valuing excellence (and evidence) over autonomy Patient-centered Each patient is the only patient Population-based

21. CCM: Learn a new Language Self management Delivery system design Activated patient Proactive team

23. Examples of Application of chronic care model: The Health Disparities Collaboratives Partner with IHI, Univ of Washington to implement model in HRSA clinics Generate and document improved health outcomes for underserved populations; Transform clinical practice through models of care, improvement and learning; Develop infrastructure, expertise and multi-disciplinary leadership to support and drive improved health status; and Build strategic partnerships

24. Examples of chronic care collaboratives: HRSA Clinics nationally 2004: 497 health centers in the first Diabetes Collaborative, enrolled 16,000 people with diabetes. Performance measure of �two Hemoglobin A1c (HbA1c) tests done within a year� increased by almost 300%. Strong supportive partnerships with (CDC) and state Diabetes Control Programs have resulted in over $2 million in additional resources to participating health centers Sharing among participants Many barriers: If you can make it there, you can make it anywhere

25. Achievements In the first Diabetes Collaborative, enrolling 16,000 people with diabetes. The national shared performance measure of �two Hemoglobin A1c (HbA1c) tests done within a year� increased by almost 300%. Strong supportive partnerships with (CDC) and state Diabetes Control Programs have resulted in over $2 million in additional resources to participating health centers

26. Diabetes care in AHC�s

27. AAMC Project AAMC recognized need to teach about chronic care A partnership between the Association of American Medical Colleges (AAMC�www.aamc.org/iicc), Improving Chronic Illness Care (ICIC�www.improvingchroniccare.org), Rationale: health professions students and residents should learn in settings that strive to deliver the highest standard of care achievable Goal: use model for many chronic conditions like diabetes, asthma, CHF etc

28. What is unique about the AAMC Academic Chronic Care Collaborative?  Builds on the premise that academic settings are committed to implementation of innovation that is evidence-based, can be shown to benefit patients. There is the opportunity for such improvements to be incorporated into the care of future patients through the education of tomorrow�s health professionals.

29. Project Aims Improve clinical outcomes of patients with diabetes. Integrate the CCM into residency and health professions education programs. Change focus of care from provider to patient by developing a true team approach to health care. Improve collaborative relationships between the AHC and the community.

30. The Academic Chronic Care Collaborative (ACCC) First: train the trainers: attendings 22 Medical Centers: UK, Emory, Duke, Montefiore, Yale, U of L, UC, Michigan etc How to teach the �competencies�

31. What is unique about the AAMC Academic Chronic Care Collaborative?  Addresses competency areas for resident training (AGCME): Education expert part of team Commitment of time and money to projects like this when there are additional missions beyond patient care, notably research and education. Academic clinicians frequently practice medicine while having other obligations and activities; research and teaching. Academic practice sites may be loosely organized and are often autonomous in nature.

32. What is unique about the AAMC Academic Chronic Care Collaborative?  Commitment of time and money to implement transformation where there are additional missions beyond patient care, notably research and education. Academic clinicians frequently practice medicine while maintaining a larger portfolio of additional professional obligations and activities. Academic practice sites may be loosely organized and are often autonomous in nature.

33. The ACCC Timeline: 5/05 � 06/07 Strategies for learning Face-to-face interactive learning sessions Virtual learning session A Congress, coinciding with the AAMC annual meeting Monthly conference calls Grounded in the Chronic Care Model A foundational change package for improvement of chronic illness care

34. ACCC Measures: Diabetes

35. ACCC Measures (con�t)

36. Toward a chronic care oriented system Reviews of interventions in other conditions show that practice changes are similar across conditions Integrated changes with components directed at: better use of non-physician team members, planned encounters, and modern self-management support enhancements to information systems influencing physician behavior Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G.Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care. 2001 Aug;24(8):1365-70. Evidence that just guideline didn�t change process or outcome in asthma and angina: Eccles et al BMJ 2002;325:941 computerized guidelines, RCT in UKRenders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G.Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care. 2001 Aug;24(8):1365-70. Evidence that just guideline didn�t change process or outcome in asthma and angina: Eccles et al BMJ 2002;325:941 computerized guidelines, RCT in UK

38. The Goal of System Changes to Improve Chronic Illness Care

39. What are �informed, activated patients� ? They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it at home, work and school environment. Guidelines help. Are linked to a prepared practice team in a continuous relationship. Family and caregivers are engaged in the patient�s self-management. The health care provider is a guide.

40. What characterizes a �prepared� practice team?

41. Chronic Care Model: Six Tools to Make it Work Decision support Clinical information systems Delivery system design The health care organization Community resources and policies Self-management support

42. Components: Decision Support Decision support systems are employed to assure that the best available evidence is applied in clinical decision-making. Evidence-based guidelines are integrated into care, and supported by provider education, links with specialty expertise, and reminder and fail-safe systems. Guidelines are not portrayed as second-class cookbook medicine.

43. Components: Delivery System Design Emphasize team care and defines roles and tasks Team uses planned visits to support EBM care with continuing care Provides care management for high risk patients Assures regular follow-up and care coordination , making follow-up a part of standard procedure. All of the clinicians have centralized, up-to-date information about the patient�s status

44. Clinical Information System: May be electronic or mixed electronic and paper� A registry � an information system that can track individual patients as well as populations of patients � is a necessity when managing chronic illness or preventive care. Continuing care teaching practices routinely use electronic databases and functions to monitor and assure quality of care.

45. Components: Health Care Organization Organization and its leaders encourage and support better care using ongoing quality measurement, improvement & incentives. Effort to improve care should be woven into the fabric of the organization Care processes are redesigned to use improvements such as open access scheduling, greater use of non-clinicians in patient care, group visits, and e-mail. Teaching practices continuously monitor and improve care quality, and faculty and traineesevaluated and rewarded accordingly.

46. Components: Community Resources Health care organization has linkages with community organizations that can enhance practice capabilities, provide key patient services, or improve care coordination. Community: Community programs and organizations that can support or expand a health system�s care for chronically ill patients and prevention strategies (health departments, CDC teams).

47. Components: Self Management Support Very different from telling patients what to do. NOT AN OPTION OR PREFERENCE Every patient receives effective self-management interventions and ongoing collaborative goal-setting and problem solving by the team. The individual�s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.� Barlow et al, person Educ Couns 2002;48:177

48. Effective self-management Support Assess knowledge, behaviors and confidence routinely Advise from scientific evidence and present information Agree on goals and treatment plan for improving self-management Assist in overcoming barriers Arrange helpful services

49. ASSIST Collaboratively review goal(s) and identify personal barriers to reaching goals, and use motivational interviewing or problem-solving techniques to identify strategies for surmounting them. Agree and assist are the steps that lead to the creation of a personal action plan.Agree and assist are the steps that lead to the creation of a personal action plan.

50. ARRANGE Help access services (e.g., peer support group, smoking cessation program, safe exercise options) Specify a plan for follow-up

51. Effects of Self-management Education on Glycemic Control 31 RCTs evaluated effects on HbA1c Average 6 contacts and 9 contact hours Most often delivered by nurse-dietician-physician team 2/3 in groups Reduction in HbA1c increased with contact time (1% for every added 24 hours of contact)

52. Effects of Self-management Education on HbA1c Levels across 31 RCTs

53. How do we get there? Small steps: big rewards Small changes may reap big benefits Analyze each part of the model

54. Small changes lead to big effects Teams learn about specific changes that can be made within each area. Changes are then �tested� at each site, guided by the Improvement Model Part of the learning of the collaborative is the art of making small changes and learning from each change � the PDSA process. Changes that are effective are expanded. Multiple changes in high leverage areas result in transformational change. This is the �execution� part of the equation.

55. The BTS Model for Improvement was first developed by Tom Nolan and colleagues, and is described in detail in The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996). The Model for Improvement is based on the idea that every system is designed to give you exactly the results that you get from it. To get different results, you have to change the system. The three questions and the Plan, Do, Study, Act Cycle give you a method to learn how to make the changes that will result in improvement. Yesterday, we talked about the three fundamental questions for improvement. Today we will be focusing on the action part of the Model.The BTS Model for Improvement was first developed by Tom Nolan and colleagues, and is described in detail in The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996). The Model for Improvement is based on the idea that every system is designed to give you exactly the results that you get from it. To get different results, you have to change the system. The three questions and the Plan, Do, Study, Act Cycle give you a method to learn how to make the changes that will result in improvement. Yesterday, we talked about the three fundamental questions for improvement. Today we will be focusing on the action part of the Model.

56. PDSA Cycles Small changes reap big rewards Example: Plan a group visit. Do: Call 8 patients Study results. How many came? Was it a good time etc? Act and reassess. What would you do differently?

57. Three Types of Measures If you can�t measure what you are doing, you can�t improve Outcome Measures (voice of the customer or patient): Process Measures (voice of the workings of the system): Balancing Measures (looking at a system from different directions/dimensions) IT systems essential 

58. Outcome Measures (voice of the customer or patient): Outcome Measures (voice of the customer or patient):How is the system performing? What is the result? For diabetes: Average hemoglobin A1c level for population of patients with diabetes For access: Number of days to appointment For critical care: Intensive Care Unit (ICU) mortality For medication systems: Adverse drug events per 1,000 doses

59. Process Measures (voice of the workings of the system): Are the parts/steps in the system performing as planned? For diabetes: Percentage of patients with hemoglobin A1c level measured twice in the past year For access: Average daily clinician hours available for appointments For critical care: Use of adverse drug event chart review

60. Balancing Measures (looking at a system from different directions/dimensions):  Are changes designed to improve one part of the system causing new problems in other parts of the system? For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing

61. For Access Time to third next available appointment Delay from time of appointment to time to see clinician Percentage of "good" or "very good" answers on selected patient satisfaction survey questions Average daily clinician hours available for appointments Average daily demand for appointments

62. A TEAM Makes it happen The system leader: anyone with clout Clinical expert: teach somebody to be the expert Day to day team leader: organizer Information Technology support: Would be nice Deference to expertise rather than rank

63. Selecting the Front Line or Pilot Team System Leader: A system leader is the person on the team with enough clout in the organization to implement new changes Examples: a Vice President of Medical Affairs, Chief Nurse Executive, Chief Operations Officer, a Division Head, or an Administrative Director. Clinical/Technical Expert : A technical expert is one who knows the subject intimately and who understands the processes of care in the pilot area.

64. Selecting the Front Line or Pilot Team Day-to-Day Team Leader : The day-to-day leader will be the critical driving component of the front line team and the project, assuring that changes are tested and overseeing data collection. Education Expert: Resident Physician: In addition to an education expert, a resident that has longevity across the duration of the collaborative Information System Expert

65. Other members of the team Clinic personnel such as front line registration Lay workers Community health workers Health professionals: pharmacists, nutritionists, nurses Social service Psychologists

66. UK ACCC Location: University of Kentucky Hospital Affiliation: UK Hospital Residency Programs: UK Family Medicine & UK Internal Medicine Residency Clinical Sites: UK Clinics Previous Collaborative Experience: Very little

67. UK Chandler Medical Center Established in 1957. Encompasses the Colleges of Dentistry, Health Sciences, Medicine, Nursing, Pharmacy, and Public Health, as well as University of Kentucky Hospital, UK Children's Hospital and the Centers of Excellence. Mission: to help people of the commonwealth and beyond to gain and retain good health through creative leadership and quality initiatives in education, research, and service.

68. Pilot Sites/Focus Population

69. So What Have We Done Learning sessions for the trainers from the pros sponsored by RWJ. Collect resources and actually collaborate with the other centers. Weekly meetings. Monthly calls. Quarterly meetings to share. Educate anyone and everyone on the chronic care model Tried to accomplish the 6 components of the chronic care model

70. Training residents Input from the education expert from IM and FM Purpose is to fulfill competencies outlined by residency education, Boards etc Learning objectives, Curriculum, Outcome measures are being developed These are skills that they will need in the �real world�.

71. Delivery System Design: Group Visits Patient Recruitment via: Triage nurse; provider during regular clinic visit; provider referral, followed by phone call to patient by triage nurse Format of Visit: 1 � hour total time Introduction (15 mins), presentation (15-30 mins), discussion (30 mins), provider time (15-30 mins). Resident researches/teaches a topic to the patients Foot care and nutrition

72. Delivery System Design: Group Visits Special Team Member Roles Nurse manager (also the triage nurse) � recruitment/planning/arranging for healthy snacks/clinical data collection Nurse practitioner � organization/clinical care Resident Physician � presentation/clinical care Faculty Physician � a credible resource Outcomes Positive patient & provider satisfaction w/format Billings submitted easily, GV form Patient empowerment

73. PDSA Cycles: Plan, Do, Study, Act Small changes reap big rewards Example: Plan a group visit. Do: Call 8 patients Study results. How many came? Was it a good time etc? Act and reassess. What would you do differently?

74. Clinical information systems: Make a registry Gather info from 4 IM and 4 FM attendings Doc site: Tracking program to measure outcomes Bric grant for data entry Developed a new �diabetes form� with the help of IM, KDN and others Placing it on every chart. PLEASE LOOK!

75. Clinical Information System Changes Implemented: Population of DocSite Patient Registry is currently underway Restructured 2006-2007 budget to include more aggressive development & use of patient registry Plans to use registry as a QI tool for residents to evaluate progress of their patients� clinical indicators

76. Self-Management Support Changes Implemented: Group and planned visits focus on self-management of diabetes. Topics have included: nutrition, foot care, exercise/activity, medication management, & living well with diabetes Packets of information on diabetes and self management placed in file in precepting room

77. Partnering with community Partnering with community health clinics that are doing the collaborative model Hope to do �field trip� in June Chronic care conference in June so that we can share progress, barriers, get new ideas for patient education, motivation logistics DPCP resources, CDC NDEP Corrections

78. Healthcare Organization Received administrative and financial support from institutional top leadership. Received institutional support to continue teaching about the academic chronic care model after the collaborative is �finished� Incorporated the CCM into the FMC and IM residency training curricula Incorporated the CCM into the UK medical school curricula Outreach to Managed Care

79. Comparison of Measures Between Total Population & Group Visit Attendees

80. Measure: Self Management Goal

81. Measure: BP < 130/80

82. Measure: Comprehensive Foot Exam

83. ACCC Education Measures

84. Future More education of providers within UK and outside Chronic care clinic: First one March 15 Residents, intense prep session on chronic care model Serves as model for as university faculty organization deals with P4P issues, QI

85. So How Does the CCM Prepare Us for P4P It is here and we must acknowledge it. We can�t put our heads in the sand

86. Symbiotic Relationship A �healthy� community produces �healthy� potential employees who can increase productivity and positively impact the economics of a business. Healthy and productive employees can have a positive impact upon the community Employers know that it takes collaborations on several levels to nurture a healthy community, and are searching for the right partners and vehicles to accomplish this together.

87. Possibility of Decreasing Some Indirect Costs Decreased rates of absenteeism Increased presenteeism Increased rates of productivity Less short term disability in employees with chronic conditions Less stress on other employees

88. P4P is Here Nationally Response to Business Coalitions worried about worker productivity and chronic conditions and health costs. Businesses are looking at providers who deliver better outcomes. NBCH and NBGH: Bridges to Excellence down the road Pacific Business Group on Health Medicare

89. P4P in Our Neighborhood United Healthcare has report cards and has a 2 tier payment system Louisville B2E: GE, Humana, Ford etc Employees of these types of businesses are great potential UK clients CCM is one tool.

90. Bridges To Excellence �Rewarding better quality careA review of the business case

91. Bridges to Excellence: Rewarding quality across the healthcare system A multi-stakeholder approach to creating incentives for quality The Physician Office Link is a Bridges to Excellence program designed to create significant leaps in the quality of care by recognizing and rewarding health care providers who demonstrate that they have implemented comprehensive solutions in the management of patients and deliver safe, timely, effective, efficient, equitable and patient-centered care.

92. BTE Participants; Companies and Health Plans Assurant AstraZeneca Atlanta Gas Light BellSouth ChoicePoint Cingular Wireless LLC City of Cincinnati City of Colorado Springs City of Fort Smith Home Synovus Triumph Airborne UPS Verizon Xerox Aetna Blue Cross Blue Shield of North Carolina CareFirst Blue Cross Blue Shield CDPHP CIGNA Kaiser of Georgia MVP Health Care UnitedHealth Group Humana Wellpoint

93. BTE Performance Dimensions

94. Reward Example 3 PCP Practice with 1000 patients covered by the program: �3.5% are diabetic patients �2.5% are cardiac patients �Practice receives total of $54,800: �$40 * 1000 = $40,000 for meeting POL measures �$80 * 60 + $10 * 1000 = $14,800 for meeting DCL & CCL measures �Purchaser saves a total of $55,000 less program costs ($5 pmpy) Incentives have to be compelling enough that physicians cannot afford to ignore them.

95. Wagner et al In JAMA, 2001, 2003 Wagner�s Chronic Care Model demonstrates annual incremental savings between $650 and $950 per diabetic patient per year for patients with elevated HbA1c �National benchmarks indicate that between 30% and 40% of diabetic patients are not controlled �Applying a factor of 35% to the mid-point of the savings yields average expected savings of $280 per patient �Mid-point of Hewitt and Wagner model yields average savings of about $350 per year

96. Estimated Overall Impact & Available Incentive Pool Better Management of Chronic Conditions:�Hewitt analysis identifies 5% gross potential opportunity�Reduce by 1/3 to take into account current impact of good care (diabetes defect rate at 67%)� Reduce by 1/3 to take into account that we�re only focusing on the physician-faced interventions, not patient faced interventions� Net opportunity of 1.7%of total spend

97. Breakthrough in Chronic Care Program A significant gap between the care recommended for patients and the care patients actually receive. Lack of coordination between medical groups/IPAs and health plan disease management efforts. PBGH manages and administers this project to serve as a catalyst to improve the quality of care delivered to California 's chronically ill population and to advance the implementation and spread of the Chronic Care Model.

98. PBGH BCCP: Current Activities System-wide efforts to support and promote the re-redesign of health care to meet the six IOM Aims for health care: � Safe, Timely, Effective, Efficient, Equitable, Patient-centered. Physician Group collaboratives to accelerate the creation and optimization of care management systems that support the adoption and spread of the chronic care es:

99. Summary Businesses are driving health care: They buy insurance Chronic conditions must be managed more effectively Business are looking at directing their employees to select providers who have tools to improve outcomes Medicare is also looking at quality measures

100. Summary One proven method is the implementation of the chronic care model and its 6 components It is a business decision, necessary to attract patients to use UK It is a Quality improvement issue: NCQA likes the CCM It is the right thing to do.

101. What Can a Practitioner Do? Tap the local health department resources (diabetes team, CVD team) Develop a registry Use a preprinted form (Kentucky Diabetes Network) to remind and to document aspects of care Documentation helps when �pay for Performance� audits occur

102. What Can a Practitioner Do? Adult learning; get the tools from Institute for Health Care Improvement www.ihi.org Set up a planned visit, proactive not reactive Schedule an office group visit (yes, there is a billing code) Guide the visit: diabetes 101, general concepts Assume nothing!

103. Small steps: Big rewards Can�t transform everything at once Use the web sites to print out forms and �recipes� Don�t re-invent the wheel Learn from others

104. Summary Team approach Train everybody in your office Model is NOT just for diabetes, works for asthma, CVD etc Patients are hearing about group visits and like them (interaction with peers, like group therapy) Managed care is learning about group visits and likes them

105. Resources http://www.ihi.org: Institute for Healthcare Improvement, tools to print , �how to� manuals http://www.healthdisparities.net: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc) http://betterdiabetescare.org: info for practitioners

106. Resources http://www.Improvingchroniccare.org Educational materials for patients http://www.kentuckydiabetes.net http://www.aace.com http://ndep.nih/gov http://www/cdc/gov/team-ndep http://www.diabetesatwork.org

107. Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review and JAMA Re-review About 40 studies, mostly randomized trials Interventions classified as decision support, delivery system design, information systems, or self-management support No single element emerged as essential or superfluous, but 19 of 20 studies which included a self-management component improved care. All 5 studies with interventions in all four domains had positive impacts on patientsRenders et al, Diabetes Care, 2001;24:1821 Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910