Diabetes is a devastating disease, the complications of which result in premature death or disability for many Americans. Although clinical trials demonstrate the efficacy of type 2 diabetes management as well as lifestyle interventions to prevent and delay diabetes in those with pre-diabetes, there is a substantial gap between optimal care management and prevention and what is currently delivered in practice. Patients, both with and at-risk for diabetes, receive their health care predominantly through primary care practices, which base their care delivery on the traditional model of acute, episodic care delivered by individual physicians. The Chronic Care Model (CCM) provides an alternative framework to address chronic and preventive care. Key elements include self-management support, delivery system design, decision support and clinical information systems. Research demonstrates that the CCM improves both care delivery and outcomes for patients with diabetes, however, financial sustainability of the CCM in primary care, where practices depend almost entirely on fee-for- service reimbursement, has presented a major barrier. Reimbursement strategies supporting chronic and preventive care are emerging, but have not yet been tested at the practice level in a fee-for-service payment environment. Therefore the focus of this proposal is: How can primary care practices implement and sustain the CCM for patients with, and at-risk for, diabetes within a predominantly fee-for-service payment environment? In this study, we will implement the CCM focusing on two organizing strategies: 1) clinical information system to prompt, remind and report for systematic decision support to clinicians and their team, and 2) care managers to support patient self-management and prevention. Integrated Health Associates (IHA) is a Michigan-based, physician-owned group of practices that receive predominantly fee-for-service payment. Their ten primary care practices will participate with half randomly assigned to intervention and half as usual care comparisons.
Study aims are: 1) To implement the CCM, focusing on the implementation of clinical information systems and care management, for patients having and at risk for diabetes, into primary care practices, and to describe qualitatively and quantitatively the barriers, facilitators, and methods used to accomplish successful integration. 2) To identify and measure financial sustainability of CCM implementation on two levels: a) the intervention practice's capacity to generate new sources of income to cover the direct costs of the clinical information systems and care managers and b) completing a full cost effectiveness analysis of the CCM implementation with regard to the total costs to practices, patients and the health care system versus benefits accrued by participating patients. 3) To measure outcomes of practice-level CCM implementation on patient's physiologic indicators and health behaviors. Primary measures include HbA1c, blood pressure, lipids, fasting blood sugar levels, and BMI, as compared to similar patients in comparison practices, at one year follow-up. Secondary measures include diet, physical activity, alcohol and tobacco use.
Diabetes is a leading cause of premature morbidity and mortality among Americans. Although effective strategies exist to help patients with diabetes reduce complications of the disease, and patients at risk to delay or prevent their development of diabetes, these strategies are not consistently implemented in routine primary care medical practice. This study seeks to implement Chronic Care Model-based diabetes prevention and self care in primary care, remove barriers to sustained care delivery (including financial sustainability), and measure the effect of this implementation on care processes, health care costs, and patient's clinical, health behavior and care satisfaction outcomes.