• Identified asthmatic patients from three clinic sites (Family Practice, Internal Medicine, and Pediatrics)
• Data analysis on identified patients pertaining to hospitalizations and Emergency Department visits within a one year period of time (July 1, 2001 – June 30, 2002)
• Data analysis comparison on costs of hospitalizations or emergency room utilization of identified asthmatic patients
• Used a comparison group to track differences in increase/decreases 

Three sites (Family Practice, Internal Medicine, and Pediatrics) adopted the Chronic Care Model as part of a larger Robert Wood Johnson Foundation grant from the Partnership for Quality Education.  The focus of the grant was to develop and implement a teaching curriculum based on the Chronic Care Model. Using AH! (Asthma Health) as a model for chronic illness care, these sites implemented an intervention consisting of a redesigned team approach, an emphasis on patient self-management skills, and the use of registries to track populations of patients.

• Treatment guidelines were embedded into patient encounters
• Patient self-assessment forms were created and filled out by asthmatics while waiting to see their health care providers
• Office and physician staff developed a team approach to patient care
• Developed didactic sessions teaching various aspects of the Chronic Care Model in small segments to be presented to Resident Physicians
• Offered faculty development sessions in three disciplines to expose attending physicians and clinical staff to the Chronic Care Model and how it relates to required elements of teaching in a teaching hospital (i.e., the ACGME competencies)
• Provided protected time for Resident Physicians to spend time studying quality improvement
• Joined other collaborative efforts in our community and state in order to continue quality improvement efforts in the three clinical sites
• Developed a coordinated team approach to chronic illness care that involved tracking the flow of the asthmatic patient in each clinical site, and identifying the barriers for patients and staff to practice good quality health care
• Identified and clarified roles and responsibilities for each team member beginning with the first phone call from the patient to the call center to the completion of the visit by the health care provider
• Developed a method to track team successes and missteps

Summary of Results:

There was a very substantial reduction in asthma related ED visits and hospitalizations in all three sites varying from 51 percent in Internal Medical Clinic, 40.7 percent for the BBCH Pediatric Clinic and 36.5 percent for the Family Practice Center.  The reduction among the clinic patients was far greater than the 5.5 percent reduction in asthma ED visits and hospitalizations observed for all patients using the MMC during the same time period.  The difference in utilization among clinic patients resulted in savings over $60,000.  There was also a moderate reduction in non-asthma related ED visits and hospitalizations for the clinic population.

Lessons Learned:

• Create partnerships.  Partnerships are vital in areas including patients, providers, and community agencies.  When all are playing on the same field, it is easier to accomplish and demonstrate improved outcomes for patients and the health care system.
• Assess strategies mid-cycle. By evaluating your ideas halfway through the proposed study cycle, you can continue on or develop a mid-course correction in order to achieve maximum learning.
• Be patient. Rapid cycles of change involve patience! Every idea does not produce results but keep trying!
• Communicate often with everyone! You can never communicate too much with those involved with your project or with those working in the trenches. New ideas are more readily received with frequent communication.
• Listen to those around you. If you think you are communicating but are never showing signs of listening to others, you will be viewed as dogmatic and lose momentum.
• Align your vision with that of the institution. If what you do advances the goals of the institution, you are more likely to gain support from senior leadership.
• Throw your rocks in the water one at a time! This will create a ripple effect and you are more likely to achieve sustainable success.  If you throw all the rocks in at once, you may make a big splash, but it may die out quickly.
• Slow down. It is always tempting to work fast in order to achieve results but you can work too hard and, in the end, disenfranchise people who are important to your success.

Victoria W. Rogers
Kids CO-OP (Clinical Outcomes and Outreach Program), Director
Maine Medical Center Portland
rogerv@mmc.org

[Storyboard presentation at IHI's National Forum, December 2004]