A fundamental challenge for the US health system remains quality improvement of chronic disease diagnosis and treatment.
This series begins with the work of Schrader and colleagues at the Carle Clinic of Illinois, which is one of 16 national sites selected by the Centers for Medicare and Medicaid Services to test programs aimed at chronically ill Medicare beneficiaries. It is an initiative to focus on best practices, and the focal organization of this article is Carle's Medicare Coordinated Care Demonstration (MCCD). The study uses a prospective, longitudinal randomized treatment-control group design approach to assess the effectiveness of Carle's MCCD. Individuals are enrolled in the demonstration if they have a diagnosis of coronary artery disease, congestive heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma; live in the 13 county service areas; and have Medicare Parts A & B. The Carle MCCD is reimbursed a per member per month fee for every treatment group patient enrolled. These payments fund the clinical operation of the demonstration, including staff salaries/benefits, physician reimbursement for patient and team conferences, expanded patient services, and education of providers and patients. Through August 2004, Carle has enrolled 2702 patients.
The interventional components of the Carle MCCD parallel those of the Chronic Care Model. The components include (1) the healthcare organization; (2) community resources and policies; (3) delivery system design; (4) self-management support; (5) decision support; and (6) clinical information systems. The first 2 components emphasize an organization's commitment to new ways of care delivery and integration with the community. The other components provide the foundation for effective chronic care delivery.
Four of these articles examine developments in technologies in the ambulatory care programs. Gamm, Nelson Bolin, and Kash, researchers from Texas A & M University, consider selected structural and technological attributes of chronic disease management programs in their article. They consider 4 systems in 4 different states, which are built on multispecialty group practices and include a major clinic, multiple primary care sites, hospitals in 3 of the 4 systems, and 1 or more health plans. The disease management programs function under different internal auspices and support across the 4 systems, employ a variety of technologies, pursue management of a number of chronic conditions, and are viewed positively on a number of criteria by participants in all 4 systems. Through interviews and survey data collection, the researchers are able to study the variety of social, administrative, and clinical organizational technologies and the implications for disease management.
Prince's group at Northwestern University describe the integration of traditional ambulatory care services with telehealth technology services, which now allows delivery of “virtual assisted living” services at home that can more efficiently meet Senior health requirements, and can simplify other aspects of a Senior's life that can play a role in extending time at home. They begin their discussion with the documentation of the increasing number of individuals who are choosing to die at home, which has lowered the demand for nursing home services. They stress the importance of centralizing key data, which can be accessible to the Senior's doctors, family members, and other healthcare providers. They explain the concept of “virtual care” and use NorthShore eCare as an example of companies looking at the cost-effectiveness of such traditional and electronics-based care service integration. They present the information and communication requirements for a set of common ambulatory care services that must be addressed if the patient is to be treated extensively at home. In presenting these arrangements, they raise the proposition that these service configurations may actually increase the quality of care for the patient and at the same time enable the individual to “age in place” at home.
Chumbler and colleagues of the University of Florida focus on a patient-centered care telehealth program where the enrollees of the program were matched with disabled veterans of a cohort that received no such intervention. Telehealth of course enables the patient to be seen “just in time” and reduces traditional barriers to the access of services. There were 400 patients involved in the study and service use outcomes were assessed 12 months before and 12 months after enrollment. The research design of this study addressed some serious design flaws of previous studies in this field. The study uses an adapted version of the Chronic Care Model.
Finally, Soban and colleagues of UCLA examine how different organizational factors influence the quality of preventive care. This study also uses VA patients and looks at discrete changes in the organizational factors. The study uses a retrospective concurrent matched cohort study design. Combining facility-level data from a national organizational survey and centrally available, externally abstracted chart review data on prevention performance, they assess the relationship between structural features of primary care departments and the quality of preventive care delivered. Primary care practice resources were found to be associated with the delivery of 9 preventive services. They adjusted for facility size and academic affiliation, and the resource arrangement, which accounted for the variation in those 9 services.
Barry R. Greene, PhD
Department of Health Management and Policy, University of Iowa, Iowa City