Background

1. Applying the Chronic Care Model across multiple conditions: A planned care quality improvement initiative in the Indian Health System INDIAN HEALTH SERVICE * PHS * 1955 * • Cindy Hupke, RN, MBA1; Ty Reidhead, MD2; Bruce Finke, MD2; Pat Lundgren, RN, EdD2; Lisa Dolan-Branton, RN2; Gerald Langley, MS1; Tracy Jacobs, RN1; Lindsay Hunt, BA1; Kedar Mate, MD1; Don Goldmann, MD1 • 1Institute for Healthcare Improvement, Cambridge, MA, 2 Indian Health Service, Rockville, MD Limitations Background Methods Results • Fourteen pilot Indian health facilities responded to a request for participation and were enrolled in the IPC collaborative based on the Breakthrough Series Collaborative model. • From March 2007 to August 2008, microsystems (i.e. group of providers and patients at a facility) identified, tested, and implemented changes to improve chronic care and preventive processes and patient experience, by utilizing: - organizational and community assessment tools - process flow diagrams - rapid cycle improvement methods (plan-do-study-act cycles) • Sites shared learning through virtual meetings, a mutual listserv, and extranet. • Composite measures were used: • - Intake screening bundles: alcohol use, depression, body mass index, blood pressure, domestic violence and tobacco use • - Cancer screening bundles: screening for colorectal, cervical and breast cancer • - Diabetes comprehensive measures includes key processes of care • Data from sites were tracked using web-based monthly reporting tools on the extranet and analyzed using weighted averages in Microsoft Excel. • Chronic and preventable conditions result in a high burden of illness in American Indian and Alaska Native peoples. • In 2006 the IHS launched the Chronic Care Initiative (CCI) with the aim of improvement in clinical prevention and the management of chronic conditions using the framework of the Chronic Care Model. • The Innovations in Planned Care (IPC) collaborative focuses on strengthening the relationship between the prepared, proactive care team and the patient, family, and community. • Improvement is guided by measurement in four domains: - preventive care - management of chronic conditions - patient experience of care - cost of care • Participating sites self selected to participate and were motivated to improve. • There was no control group to compare findings. • Minimal data on cost of changes in the system was obtained. Conclusions • Using change concepts derived from the Chronic Care Model, collaborative teams improved clinical prevention, management of chronic conditions, patient and experience of care. • Follow-up is planned to identify the optimal set and sequence of changes to ensure sustainability and spread of these improvements.