Background
Methods
Data sources
Concept*
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Relevant key words**
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Primary Health Care | Care, Primary Health; Health Care, Primary; Primary Care; Care, Primary; Primary Healthcare, Healthcare, Primary |
General Practice | General Practice |
Family Practice | Family Practices; Practice, Family; Practices, Family |
Chronic Care Model | ‘Chronic Care Model’ |
Study selection
Data abstraction
Domain
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Definition
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---|---|
Intervention characteristics
| The characteristics of the intervention being implemented include whether: the intervention is perceived to be developed external or internal to the organization, there is evidence supporting its effectiveness, and its implementation will be advantageous to its alternatives. Other characteristics include how the intervention is presented, its adaptability, complexity and whether it can be tested on a smaller scale. |
Outer setting
| The external context of the organization includes: patient needs and the ability to meet them, networks with other organizations, pressure to implement the intervention and external policies and incentives to adopt the intervention. |
Inner setting
| Features of the organization including its structural characteristics (such as size, age of the organization and division of labour), networks and communication (such as connections and information sharing between individuals, units and services), cultural norms and values, implementation climate, organizational capacity and readiness for change. |
Characteristics of individuals
| Staff knowledge and belief about the intervention, their ability to execute their respective aspects of the implementation, and their individual stage of change. Other characteristics include individual identification with the organization and other personal attributes. |
Process
| Active change process, the purpose of which is to promote uptake of the intervention by the organization. This is influenced by the level of planning prior to implementation, and engaging organization stakeholders through appointing implementation leaders and champions of the intervention. This includes the ability to execute the implementation of the intervention as planned and to continuously reflect on and evaluate the quality of implementation and intervention as it progresses. |
Results
Reference/Location
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Study design, methods
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Participants (n)/ study setting
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Objective
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CCM
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Intervention
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[34] Mexico | Quantitative, pilot study, survey assessing chronic care delivery, and measurement of clinical outcome | Primary care teams (n = 10): physicians, nurses and other professionals were randomly selected and assigned to intervention or control group | Evaluate whether implementation of diabetes quality improvement (QI) project improved patient outcomes | A, B, C, D, E, F | Implementation of QI strategy for diabetes care based on three learning sessions, followed by Plan, Do, Study, Act (PDSA) practice |
[35] USA | Quantitative, pilot study | Registered nurse, general internists and multi-morbid patients in an urban primary care practice | Assess feasibility of implementing the Guided Care Model | A, C, D, E, F | Guided Care Nurse worked with two physicians to conduct geriatric evaluation, disease management and to coordinate care. |
[36] [USA] | Quantitative, nonrandomized-prospective clinical trial, survey measuring primary care experiences | Older community patients (n = 150), Registered nurse, general internists (n = 4) in an urban primary care practice | Evaluate intervention to enhance the quality of primary care experiences in chronically ill older persons based on Guided Care model | A, C, D, E, F | Guided Care Nurse provided geriatric assessment, a comprehensive care plan, proactive follow-up, coordination of care, and access to community resources |
[19] [USA] | Mixed methods study, triangulation of measured clinical processes and outcomes, provider surveys and semi-structured interviews | Team leaders and members (n = 106) in 19 community health centres (CHC)s participating in diabetes QI collaborative | Evaluate whether the Diabetes Health Disparities Collaborative can improve the quality of care in CHCs | A, B, C, D, E, F | CHCs formed QIs teams which attended collaborative learning sessions and adapted QI plans using the PDSA design |
[37] USA | Quantitative study, self-administered questionnaires on CHC staff | Staff (n = 622) of CHCs (n = 145) participating in QI initiative | Assess predictors of changes in staff morale and burnout at CHCs participating in Health Disparities Collaborative | A, B, C, D, E, F | CHCs participated in quarterly regional or national learning sessions and developed QI teams which utilized the PDSA model |
[38] [USA] | Quantitative, matched control study, organizational survey, and measurement of care process | CHCs (n = 19) in Health Disparities Cancer Collaboratives, and controls (n = 22) in underserved population | Assess whether CHCs in collaboratives were more likely to implement cancer care process changes | A, B, C, D, E, F | CHCs formed teams to learn how to implement change, facilitated by an expert faculty. Health centers reported and shared QI experiences during monthly teleconferences and three in-person learning sessions |
[39] USA | Qualitative study, semi-structured interviews, using grounded theory approach | Primary care physicians (n = 24) in multi/single specialty groups or single practices | Examine primary care physicians’ views on obstacles to providing depression care and CCM-based interventions | A, B, C, D, E | Depression screening, structured assessment, patient education, mental healthcare integration, consults and care management |
[40] USA | Qualitative study, semi-structured interviews, observational notes | Leaders and front-line physicians and nurses (n = 53) in a large multispeciality health group (clinics, n = 5) | Evaluate care changes and processes used to implement CCM | A, B, C, D, E, F | Project leaders and multidisciplinary teams were created to guide implementation, and individual care teams piloted the intervention |
[41] USA | Quantitative study | Physicians (n = 17) and nurse practitioners (n = 5) in a metropolitan family practice clinic | Describe steps to successfully implement clinic-in-a-clinic diabetes self-management that uses PDSA | A, B, C, D, E, F | Education, behaviour change support, goal setting and follow up provided by nurse practitioner to Type 2 diabetes patients who require more intensive counselling on diabetic self management issues |
[42] USA | Quantitative, quasi-experimental with concurrent non-randomized controls, measuring intermediate diabetes outcomes | General internists, nurse practitioners, pharmD, clinical health psychologist and nurses in a primary care clinic in a tertiary care academic medical centre | Evaluate intermediate outcome measures of diabetic patients in shared medical appointments (SMA) in comparison to control patients. | A, B, C, D, E | Utilised diabetes registry to identify target patients. Provided decision support by practice guidelines and by including a diabetes specialist in the team. Multidisciplinary team provided didactic group education and individual learning in shared medical appointments |
[43] USA | Quantitative study, measuring patient participation and changes in diabetes related outcomes | Diabetic patients (n = 275) in a CHC serving low-income Latinos | Assess patient engagement in self management activities and changes in glycosylated hemoglobin (HbA1c). | B | Implementation of diabetes education classes, chronic self-management classes, weekly drop-in sessions, individual counseling, daily exercise classes and bilingual services |
[44] USA | Qualitative study, structured interview based on ecological systems theory | Team leaders and members of CHCs collaborative (n = 14) | Identify strategies that contributed to CHCs’ successes and challenges in diabetes QI | A, B, C, D, E, F | CHCs assembled teams to participate in the collaborative. They were responsible for coordinating and reporting activities, and electronic registries. The CCM was implemented by a champion panel made of diabetic patients. |
[45] USA | Qualitative study, telephone interviews | Managers, mental health specialists and care managers in health care organizations (n = 5) | To understand the experiences of project participants in implementing depression improvement model. | A, B, C, D, E | Care management, an improved interface between mental health consultants and primary care clinicians, and preparation of primary care clinicians and practices to provide systematic depression management |
[46] USA | Quantitative study, measured fidelity to and intensity of CCM implementation | Health care organizations (n = 42) part of QI collaboratives (n = 3) | Measure organizations’ implementation of CCM interventions for chronic care QI | A, B, C, D, E, F | Health care organizations attended three learning sessions together to collaboratively improve performance and focus on implementing small rapid change cycles in their practices |
[47] USA | Quantitative study | Community based primary care physicians’ offices. | Evaluate the Assessing Care of Vulnerable Elderly Persons (ACOVE) intervention for adults with geriatric conditions | A, B, C, D, E | Case finding, collection of condition-specific clinical data, medical record prompts to encourage performance of essential care processes, patient education and activation, and physician decision support and education |
[18] Canada | Quantitative study, survey questionnaire evaluating physician normative practices consistent CCM | Physicians (n = 195) in walk-in clinics (n = 29), solo family practices (n = 29), group family practices (n = 104), CHCs (n = 14) and primary care networks (n = 27) | Examine implementation of CCM in different primary care practices | A, B, C, D, E, F | N/A |
[48] USA | Quantitative study | Diabetic patients (n = 70) over 65 years old in a private medical clinic | Determine whether patients in shared medical appointment meet the American Diabetes Association standards in diabetes self-management education | A, C, D | Implementation of a diabetes self management program using shared medical appointments |
[49] USA | Quantitative study, questionnaire measuring organization characteristics and care management processes | Administrative leaders of physician organizations (n = 957), including medical groups (n = 621), independent practice associations (n = 336) across the US | Examine the relationship between measures of primary care orientation and the implementation of the CCM | A, B, C, D, F | N/A |
[50] Belgium | Mixed methods study, CCM implementation survey, analysis of meeting reports | General practitioner (n = 83), dietician (n = 1), pharmacist (n = 46), podiatrist (n = 5) and nurses (n = 90) providing care to type 2 diabetes patients (n = 2300) | Assess degree of implementation of CCM, and facilitators and barriers encountered | A, B, C, D, E, F | Development and implementation of education program for patients on diet or oral therapy, establishment of a local steering group, appointment of program manager, provider education and regional audit |
[51] Canada | Qualitative study, structured interview with staff | Health administrators, physician leaders, nurses and physicians (n = 12) in a large integrated academic institution. | Examine strategies that promote physician involvement in planning and developing of heart failure care delivery | A, B, C, D, E, F | Detailed analysis of existing heart failure management strategies, a review of best practice strategies and potential future best direction for increased effectiveness |
[52] Netherlands | Qualitative study, semi-structured interview of project managers | Project directors and managers (n = 16), in health care provider groups (n = 5) | Understand the development, implementation and execution of disease management programs by project leaders and clinicians | A, B, D, E | Implementation of nation-wide disease management program in health organization in the Netherlands |
[53] [USA] | Qualitative, case study analysis using interviews | Staff and patients from disease-specific shared medical appointments groups (N = 3) | To describe the roles of nurse practitioners in shared medical appointment group visits | A, B, C, D, E, F | Implementation of nurse practitioners in shared medical appointments |
Construct
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Domain
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Facilitator [reference number]
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Barrier [reference number]
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1. Intervention characteristic
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A. Intervention source
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B. Evidence strength & quality
| “Limited guidance on prepared practice team development” [40] | ||
C. Relative advantage
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D. Adapability
| “Integrating Guided Care nurse in work flow” [36], “Processes integrated in to existing clinical operations” [43], “CCM adaption within context of daily practice” [48], “Program tailored to region needs” [50], “Adapting communication system to local context” [52], “Integrated project to routine care” [52] | ||
E. Trialability
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F. Complexity
| “Intervention was too complex, targeted different components resulting in many priorities” [50] | ||
G. Design quality & packaging
| “Intervention was too disease specific and did not address chronic care principles” [45] | ||
H. Cost
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2. Outer setting
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A. Patient needs & resources
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B. Cosmopolitanism
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C. Peer pressure
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D. External policies & incentives
| “Poor organization of primary care in region” [50] | ||
3. Inner setting
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A. Structural characteristics
| “Development of prepared practice teams” [40], “Electronic medical record (EMR) implementation and clinic remodelling” [39], “Recruitment of multilingual staff and interpreters to address language barriers” [44], “Worked with human resources to change organizational policies” [44], “Role of specialist in supporting and supervising other staff” [45], “Addition of technology system” [52], “Nurse practitioner role in implementation” [53] | “Staff turnover” [19], “Large size of medical group” [40], “Unions unsupportive of staff role change” [40], “Medical director turnover” [38], “Need to expand role of provider” [44], “Staff turnover and loss meant very few staff could assume additional responsibilities” [44], “Lack of staff expertise in team approach to implementation” [48], “Lack of flexibility in reorganizing model of care” [52], “Smaller organizations had difficulty addressing barriers” [45] | |
C. Culture
| “Support from primary care physicians” [35], “Support from physicians” [36], “Recognition of benefit of care managers” [39], “Stable work relationships” [40], “Recognition of patient role in self management” [44], “Persistence despite extra work” [44], “Organizational culture and enthusiasm for care improvement” [45], “Promoting multidisciplinary approach” [51], “Change to patient-centred care” [52], “Receiving personal recognition” [37] | “Providers need for clear structure and autonomy” [19], “Organizational culture unsupportive of change” [40], “Lack of commitment or tradition of working in interdisciplinary teams” [50], “Difficulty changing provider care to patient-centered care” [52], “Rigid role expectations and thought processes” [52] | |
D. Implementation climate
| “Clear, shared long term commitment for change” [40], “Recognized need for change” [40], “Work credit to ensure staff buy-in” [42], “Institutional commitment for change” [45], “Commitment to follow guidelines” [48], “Provider dissatisfaction with current system” [50], “Financial reimbursement for attending meetings” [51], “Organizational will to promote change and manage change” [51] “Career promotion opportunities” [37], “Incentives such as skill development” [37] | “Lack of physician interest in addressing communication barriers with specialists” [39], “Disagreement on need for standardized care” [40], “Lack of commitment and interest by chief physician” [40], “Lack of committed vision” [45], “Difficult to motivate providers due to program uncertainty” [50], “Lack of provider commitment” [50] | |
E. Readiness for implementation
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4. Individual characteristics
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A. Knowledge & beliefs about intervention
| “Increase awareness and education about program to providers” [41], “Observation of program processes by providers” [42], “Patient registry received interest in providers” [44], “Clinical assessment tool accepted and endorsed” [45], “Information campaign to increase awareness and knowledge” [50], “Education about project goals & process” [51], “Demonstration of project benefit to physicians” [51], “Staff morale and burnout reduction associated with reports of improved care outcomes” [37] | “Needed more information on structured assessment” [39], “Unconvinced of usefulness of structured assessment for diagnoses” [39], “Lack of program information from providers that were not full time” [41], “Physician buy-in and adoption of intervention was not uniform” [47], “Fear of losing patient control to education program” [50], “Time needed for provider trust in program” [50], “Clinicians sensitive to workload and time commitment” [45] | |
B. Self-efficacy
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C. Individual identification with organization
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D. Personal attributes
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5. Process
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A. Planning
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B. Engaging
| “Supportive administration and intervention champion” [19], “Strong physician leadership” [40], “Supervisor support” [40],“Strong registered nurse leadership” [40], “Clear goals by leaders” [40], “Strong supportive leader” [45], “Commitment & support of senior leaders” [50], “Recruitment of physician champion” [51], “Engaging champions with physicians” [51], “Presence of strong champion” [37] | “Need for more senior management support” [19], “Need for intervention champion” [19], “Lack of accountability by leadership” [40], “Leaders face multiple uncertainties and distractions” [40], “Champion provider had limited time with patients” [44], “Change difficult without leadership endorsement” [44], “Lack of active provider champion” [44] | |
C. Executing
| “Coordination of program components” [41], “Target screening of at risk patients” [39], “Pre-visit screening by staff before seeing physicians” [39], “Pre-visit by nurse and clerical staff” [40], “Approached patient as a team” [44], “Health care organizations part of collaborative had high CCM fidelity and moderate intensity” [46], “Flexible meeting times and locations” [51], “Fair distribution of tasks” [37] | “Inadequate time to work on intervention” [19], “Difficulty with patient registry” [19], “Need for technical support” [19], “Competing demand of simultaneous EMR implementation” [40], “Physicians not engaged in change processes” [40], “Patient registry lacked IT support” [44], “Difficult to implement all CCM elements at high intensity in 12 months” [46], “Screening all patients time was consuming” [39], “Time constraints in appropriate assessment” [48], “Buy-in from staff not sufficient to sustain program” [48], “Increase in administrative burden” [50], “Patient involvement in own care was difficult” [52] | |
D. Reflecting & evaluating
|