Patient Health Status, Health-Related Quality of Life, and Implementation of the Chronic Care Model in Primary Care Practices

Background: The Chronic Care Model (CCM) is increasingly being used as a framework to guide quality improvement efforts in health care. This study describes implementation of CCM components adapted for preventive care and behavioral modification in frontline primary care practices. It also examines associations with three separate measures of patient reported health status and health-related quality of life.

Methods: We used data collected from the national RWJF Prescription for Health initiative. Data from three baseline survey instruments were used for this study. Two of the surveys collected data on general practice characteristics, clinical systems/structures, and care delivery processes. A third patient-level survey was administered in each practice to assess patient sociodemographic characteristics, behavioral risk factors, and self-reported measures of health status and health-related quality of life. Ordinal hierarchical linear modeling (HLM) was used to estimate categories of patient health status and “unhealthy days.” A Poisson sampling HLM approach was used to estimate frequency of reported “activity limiting days.” Analyses were conducted on a sample of 4735 patients in 57 practices located nationwide.

Results: Adjusting for patient covariates and clustering, practices that used reminder cards, computerized decision support, and individual or group planned visits were more likely to see patients in lower health categories (p<0.05). In contrast, practices that publicly reported performance measures, actively supported behavior change, integrated evidence-based guidelines into care delivery, used patient registries, and had health promotion champions on site were more likely to see patients with better self-reported health status and health-related quality of life (p<0.05). Within practices, patients with less than a high school education and lower incomes were more likely to report lower health outcomes, as were overweight/obese patients and smokers (p<0.001).

Conclusion: Findings reveal significant differences between practices and corresponding associations with patient health. The fact that sicker patients are often the recipients of more comprehensive care processes should be considered as one possible explanation for paradoxical relationships between better process and worse outcomes. Certain national recommendations for improving quality, however, are supported by study findings such as ensuring accountability, and integrating information systems and specialized health professionals into care settings. Adapting the CCM for prevention is an important step in proactively addressing health needs anywhere along the spectrum of health maintenance to disease management, and presents opportunities to reorient care delivery toward addressing risk behaviors that are leading causes of premature death and disability.