Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center.

Background: Cincinnati Children's Hospital Medical Center launched the Condition Outcomes Improvement Initiative in 2012 to help disease-based teams use the principles of improvement science to implement components of the Chronic Care Model and improve outpatient care delivery for populations of children with chronic and complex conditions. The goal was to improve outcomes by 20% from baseline. Methods: Initiative activities included review of the evidence to choose and measure outcomes, development of condition-specific patient registries and tools for data collection, patient stratification, planning and coordinating care before and after visits, and self-management support. Results: Eighteen condition teams, in sequenced cohorts, fully participated in the three-year initiative. As of October 1, 2015, data from 27,221 active patients with chronic conditions were entered into registries within the electronic health record and being used to inform quality improvement and population management. Overall, 13,601 of these children had an improved outcome. Seven of the teams had implemented their evidence-based interventions with >= 90% reliability, 83% of teams were regularly using an electronic template to plan care for a child's condition before an encounter, 89% had stratified their population by severity of medical/psychosocial needs, 56% were using registry care gap data for population management, and 72% were doing self-management assessments. Eleven teams achieved the numeric goal of 20% improvement in their chosen outcome. Conclusion: The results suggest that, by implementing quality improvement methods with multidisciplinary support, clinical teams can manage chronic condition populations and improve clinical, functional, and patient-reported outcomes. This work continues to be spread across the institution.