CA-ACCC Change Package

A change package is an evidence-based set of changes that are critical to the improvement of an identified care process. This Collaborative utilized several change packages to guide the changes tested and implemented at participating institutions during the collaborative. The Chronic Care Model serves as the foundational change package that guides improvement in chronic illness. Diabetes Mellitus, depression, cardiovascular disease (hypertension and coronary artery disease), asthma, and congestive heart failure each have a detailed change package that lists the specific changes within each component of the Chronic Care Model that have been effectively used to improve care for that condition. These change packages were distributed to teams during Learning Session I.

ICIC assisted teams in their development of change packages for new chronic conditions during the Prework phase of the collaborative. The change package is comprised of evidence-based changes that support management of the chronic illness and may include assessments, referrals, medications, and other therapies that the literature has shown improve the outcomes of patients with the chronic disease. The change package should be structured according to the care model to include decision support (protocols that improve outcomes); delivery of care (delivery mechanisms such as nursing case management that have been shown to improve care); self-management (behavioral change interventions that are supported in the literature). The change package for a chronic condition must identify at least four evidence-based changes that are critical to the improvement of care for that condition. Change packages for new diseases were completed prior to Learning Session I.
Another change package used during this collaborative is one that guides the process of medical school resident education. 

CCM Components
Decision support - The clinical care provided must be consistent with evidence-based best practices.
Patient Registries/Clinical Information Systems - In order to provide good chronic care, physicians must know who their chronic care patients are, and whether they have received the medical services that are critical to managing their illness. A mechanism for physician reminders, patient recall, and follow-up are also needed.
Patient Self-Management/Expert Patient - Patients must be knowledgeable about their chronic illness and have the skills and confidence to take responsibility for the management of their chronic illness.
Delivery System Design - Office infrastructure and clinical processes must be re-designed to accommodate planned visits, patient follow-up, and proactive care. The roles and responsibilities of office team members must be maximized to achieve effective and efficient workflow.
Community Resources - Effective community-based programs must be identified and/or developed to meet the needs of patients with chronic illness. The resources must be coordinated for maximal benefit, and patients are encouraged to participate.
Health system - A health system that recognizes the importance of improved chronic illness care and supports the redesign effort is critical for achievement of improved patient outcomes. The development of public policy that supports chronic illness management, the allocation of needed resources for chronic illness care, and the implementation of physician incentive programs that reward improved outcomes are necessary to sustain health system re-design.

Other Methodology
Other tested methodology, including the Breakthrough Series learning model and the Performance Improvement model, were used to guide improvement. The Breakthrough Series learning model, used in the IHI's Breakthrough Series, served as the framework for learning, action, and collaboration in this collaborative.   The learning model consists of 1) a pre-work period in which teams get organized to improve care, 2) a series of learning sessions where experts share information and approaches to improvement changes (collaborative teams will serve as experts later in the collaborative), 3) action periods, following each learning session, in which changes are tested and implemented by the teams, and 4) a congress where successful teams share results of the collaborative. Monthly conference calls, monthly reports, and an email listserv supported communications and sharing throughout the 12-month initiative.

The Performance Improvement Model, developed by Associates in Process Improvement and used by IHI, was used to test and implement change in chronic illness care. Three key questions form the foundation for performance improvement. In addition, the P (Plan), D (Do), S (Study), A (Act) cycle provides a methodology for the rapid cycle testing of changes within the practice setting.

Both models, the Performance Improvement Model and the Breakthrough Series learning model, were used to produce rapid and sustainable changes within physician practices, in the clinical management of patients with chronic conditions, and in the resident educational process within academic institutions.
The CA-ACCC Prework Package is available to registered CA-ACCC collaborative participants only.