Article
The Chronic Care Model and Relationships to Patient Health Status and Health-Related Quality of Life

https://doi.org/10.1016/j.amepre.2008.08.009Get rights and content

Background

The chronic care model (CCM) is a system-level framework used to guide quality improvement efforts in health care. However, little is known about its relationship to patient-level health measures. This study describes the implementation of the CCM as adapted for prevention and health behavior counseling in primary care practices, and examines relationships between the CCM and patient health measures, including general health status and health-related quality of life (HRQOL).

Methods

Baseline data from Round 2 of the Prescription for Health initiative (2005–2007) were used to assess CCM implementation in 57 practices located nationwide. Relationships between the CCM and three separate measures of health among 4735 patients were analyzed in 2007. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate categories of general health status, unhealthy days, and activity-limiting days, adjusting for patient covariates and clustering effects.

Results

Outcome variances were significantly accounted for by differences in practice characteristics (p<0.001). Practices that used individual or group planned visits were more likely to see patients in lower health categories across all measures (OR=0.74–0.81, p<0.05). Practices that used patient registries, health promotion champions, evidence-based guidelines, publicly reported performance measures, and support for behavior change were associated with higher patient health levels (OR=1.28–1.98, p<0.05).

Conclusions

A practice's implementation of the CCM was significantly related to patient health status and HRQOL. Adapting the CCM for prevention may serve to reorient care delivery toward more proactive behavior change and improvements in patient health outcomes.

Introduction

Efforts to improve the quality of care have brought forth new conceptual frameworks and innovations for redesigning the healthcare setting. The chronic care model (CCM) is a comprehensive framework featuring six major areas for quality improvement: (1) the health system and organization of care, (2) self-management support for patients to participate in managing their own care, (3) a delivery system design that proactively determines and addresses health needs, (4) decision support for clinicians based on scientific evidence, (5) clinical information systems that provide access to patient population data, and (6) linkages to community resources to facilitate care outside the clinical setting. These elements are conceptualized as fostering productive interactions between patients and healthcare providers, resulting in improved patient outcomes.1

While most empirical work on the CCM thus far has focused on the management of chronic illnesses such as diabetes, cardiovascular disease, hypertension, and asthma,2, 3, 4, 5, 6, 7, 8, 9, 10 the model has also been explored preliminarily as a template for prevention and for the delivery of services that address health risk behaviors.11, 12 This focus on prevention and behavior change is consistent with a growing sense that quality improvement in health care must facilitate a transformation of the healthcare system from its current pattern of reacting to illness and responding mainly when a person is sick to a more proactive focus on promoting health and preventing disease among individuals and populations.13, 14

Also, most studies of the CCM to date have focused on improving provider delivery of care processes (e.g., periodic measurement of HbA1c, lipid levels). Yet patient health outcomes are also important indicators of care quality. While prior studies have included such outcomes, these measures have typically been aggregated across patients within a healthcare organization.2, 4, 5 Two exceptions include recent studies8, 9 that examined disaggregated patient health measures (e.g., asthma-specific quality of life, risk for developing coronary heart disease).

The current research seeks to further this study of the CCM and patient-level outcomes and to extend knowledge of the model specifically as a framework for preventive care and behavior change. Due to the CCM's increasing popularity as a conceptual tool for quality improvement and health-systems redesign, there is need to gather more information on its uses as grounded in the reality of frontline medical practice. This study addresses three main research questions: (1) What was the status of the CCM in a national sample of primary care practices that proactively implemented this model? (2) Were CCM components that were tailored to address preventive care and health risk behaviors associated with patient health measures across practices? and (3) How did varying levels of CCM implementation relate to patient health status and health-related quality of life (HRQOL), adjusting for patient covariates and clustering effects?

Section snippets

Data Sources

This study used data collected from Round 2 of the national Prescription for Health initiative (2005–2007) sponsored by the Robert Wood Johnson Foundation. This initiative supported interventions for behavior change that were conducted in primary care practice-based research networks (PBRNs) throughout the U.S. Cross-sectional data from three survey instruments were used. Two surveys were collected at the practice level and assessed general practice characteristics, clinical systems/structures,

Results

Table 1 describes practices in the study and their implementation of CCM components. Approximately 58% of the practices belonged to a hospital or university health system, and reported moderate support for patients' behavior change, as assessed on a spectrum ranging from limited approaches (e.g., pamphlet distribution) to comprehensive involvement by behavior-change specialists. Approximately 28.1% had a multispecialty physician staff, 50.9% reported using group or individual planned visits for

Discussion

This study found that features consistent with the CCM and adapted for behavior change were implemented to a moderate degree among frontline primary care practices participating in Round 2 of the Prescription for Health initiative. Comparisons with a similar national sample of practices participating in Round 1 suggest an increased adoption of the CCM, with the most dramatic change involving the implementation of clinical information systems.12 Reported rates of using patient registries doubled

Conclusion

This study reports on CCM implementation in frontline primary care practices, and finds significant differences between practices and corresponding associations with patient health measures. Increasing adaptation of the CCM for prevention and health behavior counseling may be an important step in proactively addressing health needs anywhere along the spectrum of health maintenance to disease management. Implementing system changes that are consistent with the CCM may serve to reorient care

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