PURPOSEThe Chronic Care Model (CCM) provides a conceptual framework for transforming health care for patients with chronic conditions; however, little is known about how to best design and implement its specifi cs. One large health care organization that tried to implement the CCM in primary care provided an opportunity to study these issues. METHODSWe conducted a qualitative, comparative case study of 5 of 18 group clinics 18 to 23 months after the implementation began. Built on knowledge of the clinics from a previous study of advanced access implementation, data included in-depth interviews with organizational leaders and varied clinic personnel, observation of clinic care processes, and review of written materials.RESULTS Relatively small and highly variable care process changes were made during the study period. The change process underwent several marked shifts in strategy when initial efforts failed to achieve much and bore little resemblance to the change process used in the previously successful large-scale implementation of advanced access scheduling. Many barriers were identifi ed, including too many competing priorities, a lack of specifi city and agreement about the care process changes desired, and little engagement of physicians.CONCLUSION These fi ndings highlight specifi c organizational challenges with health care transformation in the absence of a blueprint more specifi c than the CCM. Effective models of organizational change and detailed examples of proven, feasible care changes still need to be demonstrated if we are to transform care as called for by the Institute of Medicine.

The objective of this study was to demonstrate a method to accurately identify patients with specific conditions from claims data for care improvement or performance measurement. In an iterative process of trial case definitions followed by review of repeated random samples of 10 to 20 cases for diabetes, heart disease, or newly treated depression, a final identification algorithm was created from claims files of health plan members. A final sample was used to calculate the positive predictive value (PPV). Each condition had unacceptably low PPVs (0.20, 0.60, and 0.65) when cases were identified on the basis of only 1 International Classification of Diseases, ninth revision, code per year. Requiring 2 outpatient codes or 1 inpatient code within 12 months (plus consideration of medication data for diabetes and extra criteria for depression) resulted in PPVs of 0.97, 0.95, and 0.95. This approach is feasible and necessary for those wanting to use administrative data for case identification for performance measurement or quality improvement.

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PURPOSE We wanted to determine whether a major improvement in access to primary care during 2000 was associated with changes in the quality of care for patients with depression.METHODS Health plan administrative data were analyzed by multilevel regression to compare the quality of care received by patients with depression between 1999 and 2001, a time without major changes in depression care guidelines. Approximately 6,000 patients with depression who received all care in a large multispecialty medical group during any single year were subjects for this study. Thirteen different quality measures assessed process quality under the dimensions of effectiveness, timeliness, safety, and patient-centeredness. RESULTSThe largest change was a reduction in the proportion of depressed patients with no follow-up visit in primary care after starting a new antidepressant medication: from 33.0% before a change in access to care to 15.4% afterward, P =.001. During the same period, continuity of care in primary care improved (>50% of primary care visits to 1 doctor increased from 67.3% to 74.0%, P = <.001), as did persistence of 6-month antidepressant medication (from 46.2% to 50.8%, P = <.001). Further analyses found that the latter change was primarily associated with the change in continuity of care. Measures of subspecialty mental health care worsened during this time.CONCLUSION Marked improvement in access to primary care for 1 year was associated with some improvement in primary care for patients with depression, but the mechanism appeared to be improved continuity. Those planning to implement advanced access to care need to do so in such a way that continuity of care is enhanced rather than harmed by the change. 1 This report identifi ed 6 domains or aims of quality: safety, timeliness, effectiveness, effi ciency, equity, and patient-centeredness, each of which had large gaps between "the care we have and the care we could have." Although the report identifi ed a whole series of recommendations to improve quality, it did not address the relationship between the different domains, and it is unclear whether improvements in any particular domain will improve others as well.Although the IOM reports dramatically raised the national awareness about quality, it is not clear that much has happened to change care since then, with the possible exception of what the IOM called "timeliness" ("reducing waits and sometimes harmful delays"). Recent articles suggest that many medical groups are making substantial improvements in access to primary care through using an advanced access model of patient scheduling or Second Generation Open Access. 2,3 In this approach, the goal is to offer patients an offi ce visit with the patient' s personal physician the same day the 70IMPROVED ACCESS AND DEPRESSION CARE patient requests one (if that physician is in the offi ce that day and if the patient wants an appointment that day).Although most reports about successful implementation of advanced access are either anecdotal or case studies,...