ACCC Change Package

A change package is an evidence-based set of changes that are critical to the improvement of an identified care process. The ACCC utilized several change packages to guide the changes tested and implemented at participating institutions during the collaborative. The Chronic Care Model (CCM) served as the foundational change package that guided improvement in chronic illness. In addition to the CCM, these chronic conditions -- diabetes mellitus, depression, cardiovascular disease (hypertension and coronary artery disease), asthma, and congestive heart failure -- each had a detailed change package that listed the specific changes within each component of the CCM that were effectively used to improve care for that condition.

ICIC assisted teams in developing change packages specific to other chronic conditions during the Prework phase of the collaborative. A 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 for each chronic illness was structured 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); and self-management (behavioral change interventions that are supported in the literature). The change package for a new chronic condition identified at least four evidence-based changes critical to the improvement of care for that condition. Change packages for new diseases were completed prior to the Kickoff Session.

Additional change packages can be found on the Kickoff Session Resources page.

Components of the Chronic Care Model
  • Decision support - Clinical care is consistent with evidence-based best practices.
  • Patient Registries/Clinical Information Systems - Physician know their chronic care population, and whether patients have received the medical services critical to managing their illness. A mechanism for physician reminders, patient recall, and follow-up is implemented.
  • Patient Self-Management - Patients become knowledgeable about their condition and have the skills and confidence to take responsibility for the management of their chronic illness.
  • Delivery System Design - Office infrastructure and clinical processes are re-designed to accommodate planned visits, patient follow-up, and proactive care. The roles and responsibilities of office team members are maximized to achieve effective and efficient workflow.
  • Community Resources - Effective community-based programs are identified and/or developed to meet the needs of patients with chronic illness. Resources are 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 all 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 during the collaborative to guide improvement. The Breakthrough Series learning model, used in the Institute for Healthcare Improvement Breakthrough Series, served as the framework for learning, action, and collaboration in the ACCC. 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 collaborative.

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 PDSA -- Plan, Do, Study, 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.