How to Make Systems Changes
for Improved Care

Enhanced Primary Care Model

Primary care providers have applied the principles of the Chronic Care Model in redesigning the delivery of care to persons with diabetes and other chronic diseases. These changes were predicated on the fact that the practice environment may be a more powerful predictor of the quality of chronic disease care than the specialty of the physician. The key elements of this practice model are detailed below.

Structural Elements

1. Leadership (clinical leaders/managers/administrators)
   - Identifies the need to improve chronic disease care.
2. Resources (allocation of resources)
   - Professional staff time/computer programmer time.
   - Attend meetings/absorb costs of non-reimbursed care.
3. Clinical Guidelines
   - Detailed template for care delivery.
   - Focus providers' attention.
4. Organized Team Care (Click here for more on Team Care)
   - Expanded role for nurses and other clinic professionals.
   - Need for buy-in among team members.
   - Need clear and timely communication.
5. Information Systems
   - Existing data are processed, reformatted and regularly updated to support essential tasks.
6. Activated Patients
   - Achieve better self-care/understand clinical goals/increase expectation of "control"/ better adherence to treatment.
   - Wallet cards/newsletters/group education/group care.

Functional Elements

1. Identification of Patients
   - Diagnostic data/pharmacy data/laboratory data.
2. Monitor Clinical Status or Risk
   - Monitor all parameters targeted for improvement.
   - A1C/blood pressure/lipids.
3. Prioritize
   - High-risk: not reaching goals for A1C/BP/Lipids.
   - Average risk/prevention group.
4. Active Outreach
   - Prevent lost-to-follow up through tracking.
   - Pursue patients.
5. Visit Planning
   - Pre-visit chart review.
   - Systematic or automated "real time" visit planning.

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