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A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects.

ABSTRACT: Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time.There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75).Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain.This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines:NCT00482768.

SUBMITTER: Parchman ML

PROVIDER: S-EPMC3765887 | biostudies-literature | 2013 Aug

REPOSITORIES: biostudies-literature

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A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects.

Parchman Michael L ML Noel Polly H PH Culler Steven D SD Lanham Holly J HJ Leykum Luci K LK Romero Raquel L RL Palmer Raymond F RF

Implementation science : IS 20130822

<h4>Background</h4>Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.<h4>Methods</h4>A randomized trial of 40 small primary care practices who were randomized to an initial or ...[more]

PMID: 23965255

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Project description:BackgroundMore than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting.MethodsThis systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool.ResultsThis systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care.DiscussionOverall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.

Project description:BackgroundA recent systematic review suggests that practice facilitation (PF) is a robust intervention for implementing evidence-based preventive care guidelines in primary care, but the ability of PF to improve chronic illness care remains unclear.AimsTo examine the specific activities and Chronic Care model (CCM) components that primary care practices implemented and sustained in response to a 12-month PF intervention.MethodsThe ABC trial tested the effectiveness of PF to improve care for diabetes in 40 small community-based primary care practices that were randomized to "initial" or "delayed" intervention arms. A trained facilitator met with each practice over 12-months. Facilitators used interactive consensus building to help practices implement one or more of quality improvement activities based on the CCM. Facilitators prospectively recorded implementation activities reported by practice teams during monthly meetings and confirmed which of these were sustained at the end of the intervention.Results37 practices implemented and sustained a total of 43 unique activities [range 1-15, average 6.5 (SD=2.9)]. The number (%) of practices that implemented 1 or more key activities in each CCM component varied: Patient Self-Management Support: 37 (100%); Clinical Information Systems: 24 (64.9%), Delivery System Design: 14 (37.8%), Decision Support: 13 (35.1%), Community Linkages: 2 (5.4%); Healthcare System Support: 2 (2.7%). The majority of practices (59%) only implemented activities from 1 or 2 CCM components. The number of sustained activities was associated with the number of PF visits, but not with practice characteristics.ConclusionsIn spite of the PF intervention, it was difficult for these small practices to implement comprehensive CCM changes. Although practices implemented and sustained a remarkable number and variety of key activities, the majority of these focused on patient self-management support, as opposed to other components of the CCM, such as clinical information systems, decision support, delivery system redesign, and community linkages.

Project description:BACKGROUND:Little is known as to whether primary care teams' perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients' own experience of chronic illness care. We examined the extent to which practice members' perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients' perceptions of the chronic illness care they have received. METHODS:Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice "members" (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. RESULTS:Two sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients' perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p < 0.05); Community Linkages (p < 0.02), Delivery System Design (p < 0.02), and Organizational Support (p < 0.02)] were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak. CONCLUSIONS:The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care. TRIAL REGISTRATION:NCT00482768.

Project description:BackgroundLean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects.ObjectiveTo improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics.DesignWe conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework.ParticipantsWe engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13).InterventionThe LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback.MeasuresThe primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events.ResultsThe LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation.ConclusionsHigh-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained.Trial registrationClinicalTrials.gov Identifier: NCT02936648.

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A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects.

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A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects.

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