In this study, patients with diabetes seen in practices that have implemented more CCM features were significantly more likely to receive appropriate diabetes care. In addition, physical activity counseling for overweight/obese patients was more likely to occur in primary care practices where more CCM features were implemented, particularly within practices reporting leadership that was more open to “innovation” or among obese or overweight patients without diabetes. However, no association was seen between implementation of CCM features and weight loss or diet counseling.
While associations were strongest and most significant when the CCM was considered as a whole rather than subdivided into components, correlations between components of the CCM were small to moderate. This suggests with others(1
) that none of the individual components are universally important; but rather, small efforts in several of the components or a major effort within one component may be acceptable ways to incorporate CCM features into community primary care practices and to enhance patient care.(22
) This finding is consistent with the idea that primary care practices are complex adaptive systems where a “one-size-fits-all” approach is unlikely to be successful.(29
) Each practice may incorporate features of the CCM in their practice that are most consistent with their resources, values and culture, resulting in improved patient care for that unique practice.
The effectiveness of the CCM may be diminished when psycho-social barriers or competing demands are strong. For example, in this study, with rates of counseling for diet or weight loss counseling already relatively high for overweight and obese patients (67%) as compared to previously published studies(29
), persistent barriers already recognized in the literature may limit any additional improvement due to the CCM. For example, despite comprehensive published guidelines(31
) aimed at increasing the frequency of weight counseling, physicians report feeling poorly prepared to effectively recommend weight management strategies or to develop and implement weight reduction and treatment plans.(33
) Further, while weight and obesity are delicate topics,(36
) talking about physical activity may be a way to broach the subject indirectly. This less direct approach may encounter fewer barriers and be more easily influenced by the implementation of mechanistic procedures intended to motivate physicians. Similar explanations may be found to explain why CCM implementation is effective in improving rates of physical activity counseling among patients without diabetes, but not patient with diabetes. In this case, the competing demands during the encounter of providing care to manage diabetes, its complications, or other chronic diseases may provide barriers for counseling that are difficult to overcome.(38
A study finding that has potential broad-reaching implication, not just for CCM implementation but also for implementing other care quality improvement models, practice redesign efforts, or Medical Home initiatives, is that a practice’s openness to innovation can impact how effective a model is for improving care. Existing literature identifies practice organizational characteristics (39
) that may inform these processes, such as the nature of relationships among practice members(41
), a practice’s ability to work as a team(43
), and how a practice manages knowledge (44
). Thus, regardless of the model to be used for change, consideration needs to be given to development of a practice’s organizational systems to innovate and deliver high quality care (45
), whether chronic disease management or health promotion advice and services.
A number of limitations exist for this study. Because this study was an observational, cross-sectional study rather than a clinical trial, inference of causation is not appropriate. Several clinical trials have been conducted or are underway that examine full CCM implementation within primary care practices.(23
) Additional studies have found improved patient care following CCM implementation using before-/after-implementation study designs.(48
Another limitation is the small sample (n=25) of mostly privately-owned practices located in New Jersey, such that results may not be broadly generalizable. However, of all community-based primary care practices in the US, approximately two-thirds have 5 or fewer physicians(50
). Further, the results found here reflect those from other studies.(51
) As an additional limitation, the instruments were not specifically designed to measure CCM implementation. Thus, our measurement of characteristics of CCM within practices in this secondary analysis may include both theoretical and measurement error with respect to the true intent of the CCM. However, practices in this study did not seek to implement the CCM or even have direct knowledge of the model. Further, review of qualitative data validated that practices enrolled in this study had very minimal levels of CCM implementation, most of which were captured in our surveys.
This study focused on small, mostly privately owned primary care practices, typical of the majority of primary care settings in the U.S., many of which were struggling with the basic issues related to financial solvency and staff turnover. There are a number of studies that look at weight counseling in idealized settings (52
) yet few studies adequately examine the delivery of weight counseling in the primary care setting(56
) where most people receive their care most of the time. The level of CCM implementation witnessed in this study was quite low relative to the ideal as described in the ACIC. While this may be seen as a weakness of this study, the fact that we saw effects of such low levels of CCM implementation is extremely promising in that an ordinary primary care practice which is open to innovation may not need to invest large amounts of capital and other resources in implementing the complete CCM in order to see positive results.