Experience
Since the mid-1990s, the MacColl Center for Health Care Innovation has focused on research and quality improvement efforts to improve the quality of care for the chronically ill. Patients need comprehensive chronic care, but most health care delivery systems were originally designed mainly to treat acute illness. The MacColl Center's goal is to bridge this gap.
MacColl's approach to quality improvement falls into three main areas:
- Embedding the Chronic Care Model into the drivers of national health care quality
- Increasing the efficiency and effectiveness of implementing proven quality improvement strategies, especially in small practices
- Supporting regional initiatives as laboratories for change
Diverse funding sources supporting the Center's work include national and international private philanthropic and governmental agencies.
The Chronic Care Model
Definitions of "chronic condition" vary, with some more expansive than others. The MacColl Center characterizes it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system.
Almost half of all Americans live with a chronic condition. That number is projected to increase by more than 1 percent per year through 2030, resulting in an estimated chronically ill population of 171 million. Nearly half of all people with chronic illness have multiple conditions. 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.
Overcoming these deficiencies requires an absolute transformation of health care, from a system that is essentially reactive—responding mainly when a person is sick—to one that is proactive and focused on keeping a person as healthy as possible. The Chronic Care Model summarizes the basic elements for improving care in health systems at the community, organization, practice, and patient levels.
Improving Chronic Illness Care
Improving Chronic Illness Care (ICIC), a national program of The Robert Wood Johnson Foundation, was launched in 1998. Housed in the MacColl Center, ICIC's conceptual core is the Chronic Care Model. The RWJF anthology, To Improve Health and Health Care, Volume X, provides a historical perspective on ICIC's early days. The work of ICIC is described below:
- Quality improvement
- Research
- Clinical practice tools
- Residency training
- Optimal senior care
- Networking
- International partnerships
Quality improvement: quality and equality
ICIC's Chronic Care Breakthrough Series Collaboratives began in 1999 in partnership with the Institute for Healthcare Improvement. Using a clearly defined change package based on the Chronic Care Model, these collaboratives provided participants with proven tools and information to help them make those changes within their system.
While the Breakthrough Series program was being formed, the Health Resources and Services Administration's Bureau of Primary Health Care launched its ambitious initiative to reduce quality disparities among the clients of community health centers. Since its inception in 1998, ICIC has collaborated with the Bureau and the Institute for Healthcare Improvement on the Health Disparities Collaboratives. A 2007 New England Journal of Medicine article found the Collaboratives significantly improved processes of care.
Making a case for better care
The hallmark of the Chronic Care Model is that it is evidence-based, using only those interventions that have proven themselves in research and in practice. ICIC has assembled supporting bibliographies of peer-reviewed literature covering specific chronic conditions: asthma, depression, diabetes, frailty in older people, hypertension, and congestive heart failure, in addition to the Chronic Care Model itself.
Through a Targeted Research Grants Program, ICIC provided approximately $6 million of funding for peer-reviewed, applied research addressing critical questions about the organization and delivery of chronic illness care in health systems. Grants were used by researchers and practitioners in managed care organizations, group practices, academic institutions or research organizations; applicants from both the private and public sectors were welcomed.
Practice change tools
- ICIC created a Planned Care Visit presentation to offer a practical demonstration of the specific ways that health care teams can improve care for their chronically ill patients. The 34-minute presentation takes viewers on a planned care visit in a typical office setting, from start to finish, and from the perspective of patient and provider. While a diabetes patient is featured, these same elements of planned care can be applied to people who live with any chronic condition.
- A four-part PBS series, Remaking American Medicine: Health Care for the 21st Century, features ICIC's work. This television program premiered in 2006 and followed the work of an array of pioneering individuals and institutions struggling to improve health care across the nation.
- Tackling the Chronic Care Crisis provides an overview of ICIC's work and summarizes the body of scientific literature supporting the Chronic Care Model. Contents include a 45-minute talk by MacColl Director Ed Wagner, MD, MPH, originally presented in June 2004 as part of a series of lectures given at the University of Washington's Epidemiology, Biostatistics, and Clinical Research Methods Summer Session. This CD-ROM introduces the elements of the Model and describes the nationwide work of ICIC.
Enhanced residency training
Since 2005, ICIC and the Association of American Medical Colleges (AAMC) have been facilitating the adoption of the Chronic Care Model by academic medical centers through two collaboratives based in educational institutions: one national, and one focused on California.
These academic collaboratives build on the premise that academic settings are committed to implementation of innovation that is evidence-based and can be shown to benefit patients. This work is doubly important in academic settings, because of their opportunities to incorporate such improvements into the care of future patients through the education of tomorrow's health professionals.
Optimizing geriatric care
Since its formation, the MacColl Center has served as a home for clinical staff wanting to explore new ways to care for specific patient populations. A pilot senior care program by Group Health family practice physician and geriatrician Marty Levine, MD, continued this trend in 2004. Building on the lessons of the John A. Hartford Foundation-funded Senior Resource Team project, the pilot combined six senior health care programs into a complete care system, and was rolled out at Group Health's Burien and Northgate medical centers for a 24-month pilot period. The Senior Support Web offered older patients:
- Monthly group medical appointments run by primary care teams for patients interested in receiving regular medical care in a group setting
- Easy access to the team—Levine and gerontologic nurse practitioner Sandra Kennedy, ARNP—that provided tailored clinical services for patients and their families
- Systematic recruitment of patients to participate in fitness and health maintenance programs
- Automatic telephone follow-up by pharmacists to older adults started on certain medications
- Specialized services for patients and families confronting dementia
- Support and coaching of patients and families, starting with hospitalization and continuing as patients were rehabilitated and transitioned home
Building the field
A major objective of ICIC has been to build and support the field of chronic illness care. To that end, we designed a series of meetings to stimulate interaction among front-line practitioners, researchers, and policy-makers. In addition to providing a venue for innovators across the country to connect with one another, goals for the three-year Innovations in Research and Practice Congress program were to identify the most promising ideas for improving care and priority directions for research and policy development.
The MacColl Center and the California HealthCare Foundation gave the networking process a major boost by convening a national conference near San Francisco in November 2006. About 80 leaders of 40 organizations in 17 states spent a day and a half together, sharing lessons learned and exploring ways to strengthen their individual and collective efforts. The conference helped crystallize a national perspective on quality improvement, grounded in the practical experience of these diverse participants.
International partnerships
The following are among the Center's scientific collaborations:
- The World Health Organization (WHO) approached Wagner and his team to work on an initiative to adapt the Chronic Care Model for developing countries. The major product of this partnership was the 2002 WHO global report, Innovative Care for Chronic Conditions: Building Blocks for Action. The report made the case for restructuring or developing primary care systems capable of providing high-quality chronic illness care.
- The MacColl Center has hosted five Commonwealth Fund Harkness Fellows in Health Care Policy and Practice since 2000. The Harkness fellowships provide a unique opportunity for mid-career health services researchers and practitioners from select international locations to spend up to a year in the United States, conducting original research and working with leading health policy experts. MacColl has hosted the following Harkness Fellows: Bert Vrijhoef, PhD (2008, the Netherlands); Rhiannon Tudor Edwards, DPhil, MA (2004, Wales); Malcolm Battersby, MBBS, PhD (2003, Australia); Ngaire Kerse, PhD, MB, ChB (2002, New Zealand); and Linda Gask, MBChB, PhD (2000, England).
- Agreeing that health systems worldwide must become more proactive, in April 2008 distinguished experts from Europe and the United States convened at the Rockefeller Foundation Bellagio Study and Conference Center in Italy and designed the Bellagio Model on Population-Oriented Primary Care: a comprehensive reference framework for accessible, continuous, comprehensive, population-oriented primary care.
The Bellagio conference was called "Improving primary care in Europe and the US: Towards patient-centered, proactive, and coordinated systems of care." Practitioners, researchers, and policy advisers together examined various approaches and strategies based on case studies and technical papers originating from the United Kingdom, Denmark, Spain, United States, Germany, France, the Netherlands, Poland, and Estonia. Participants also assessed technical and managerial findings from health services research—issues that are critical for primary care and health care improvement overall.