The participating practices adopted most elements of the CCM, including development of inter-professional teams, delegation of provision of care by appropriate team members, implementation of patient self-management strategies, group visits, proactive patient management—anticipating the needs of patients as opposed to providing reactive management—and use of an information system to track individual patient measures. In addition, resident training programs successfully incorporated educational strategies for learning the elements of evidence-based chronic illness care.
Resident practices, by their nature, facilitated practice redesign to implement the CCM. For example, residents, as frontline caregivers, were effective and active participants in redesign and CCM implementation. In addition, evidence-based practice was highly valued and readily adopted in these training settings8
. Similarly, residents are by nature competitive in their commitment to providing good patient care17
; hence, teams both competed and readily learned from each other as change strategies were adopted across the diverse Collaborative settings19
. The need to address ACGME competencies for accreditation purposes17,18
—particularly practice-based learning and systems-based practice—provided an opportunity to address multiple demands on learners and academic institutions.
Nevertheless, implementation of the CCM in these settings required a substantial redesign effort even for these highly motivated practices20–22
. The progression during the collaboratives of ACIC average scores to 5-8 (out of a possible 11), while reflecting change in the practices, speaks candidly to the challenge of achieving full implementation of the CCM in these resident practices.
The baseline findings in the national Collaborative—only about one-third of patients in these highly committed resident practices were initially within accepted guidelines for six clinical and process measures—reflects the challenge that good diabetes management presents in these teaching settings and emphasizes the imperative for improvement. Similar baseline findings for diabetes control have been observed in studies of chronic illness care in Community Health Centers in the US23
, while observations in private practice settings generally show higher baseline levels of control24
Previous reports suggest the importance of continuity experience both for residents and their patients in the improvement of diabetes outcomes. Warm and colleagues reported the ability to effect change in clinical outcomes using the CCM17
. Of note, these observed changes occurred in a residency program that included a yearlong ambulatory block. Dearinger and colleagues also demonstrated that extensive commitment to continuity was required to have a significant impact on clinical outcomes in patients with diabetes in residency settings25
. While the CCM emphasizes strategies for continuity of care, timely and continuous care is a challenge for most resident practices and may have played a role in the modest improvements in clinical outcomes in this report. Such continuity is made difficult, for example, by the obligations for residents to meet regularly changing assignments that include demands for acute care of seriously ill hospitalized patients, and the effects of regular turnover in resident clinic staffing.
There are several limitations to interpretation of the findings that we report here. First, we cannot say with certainty that improvement observed in the care of the patients in these initiatives was due solely to adoption of the CCM. There was no control group. Moreover, the trends in healthcare delivery that increasingly give attention to good chronic illness care were unfolding during the time that these Collaboratives took place. This was particularly true in California where considerable support already existed for change of this type26
. This is also suggested by the higher scores for clinical outcomes both at the outset and conclusion of the California Collaborative compared to the national Collaborative. At least some of the benefit may result from the greater attention provided patients simply because they were the focus of these redesign initiatives. Second, while we cannot determine that implementation of the CCM will result in long-term reduction in morbidity and mortality based on the changes in these 18-month Collaboratives, control of the principal clinical measures in the CCM (blood pressure, LDL and HgbA1C) has been documented to reduce over time the prevalence of microvascular disease in persons with diabetes as reflected in cardiac disease and stroke. Third, whether the changes observed in these programs can be replicated in other settings depends on the presence of many of the leadership and cultural characteristics that were found in these participating institutions3,4
. Nevertheless, these early adopter institutions may possess other inherent characteristics that were not readily apparent. Insights may be found in this regard by examining further the differences between the institutions that initially joined these Collaboratives but were unable to sustain their participation. Finally, whether these changes can be sustained over time in these institutions will depend on additional resources along with continued strong leadership and a supportive culture.