Utilizing the collaborative technique enabled the primary care practice teams to make many changes in the way they cared for patients with chronic illness. It was concluded that the evidence suggested improvements in patient outcomes resulted from this intervention.Subsequent to the late 1990s, more evidence in support of the model appeared. Due to the general popularity of the model, in 2001 ICIC’s three-year Targeted Research Grants Program provided funding for peer-reviewed, applied research that focused on addressing critical questions about the organization and delivery of chronic illness care within health systems. Nineteen projects were selected, providing grants totaling approximately $6 million dollars backed by the Robert Wood Johnson Foundation. The research included evaluations of interventions such as group visits or care managers, observational studies of effective practices, and the development of new measures of chronic care. The settings for these studies were primarily community or private health care. Identifying the types of organizations that fare better at improving outcomes for particular disease states continues to be a question for the literature . The not-for-profit and private sectors continue to embrace the CCM, and organizations like the ICIC continue to devote resources to its development and ability to improve on patient health outcomes. In 2001, the Institute of Medicine published what is now considered a seminal report in the field: Crossing the Quality Chasm: A New Health System for the 21st Century . In the report, the Institute of Medicine outlines six goals for the transformation of health care in the United States. The report specifically references the work of ICIC and calls upon lawmakers at the federal level to make chronic disease care quality improvement a priority issue. Following suit,vertical plant growing the National Committee on Quality Assurance and the Joint Commission, two nationally recognized not-for-profit entities that set standards for care in the United States, developed accreditation and certification programs for chronic disease management based on CCM .

At the same time, both the Joint Commission and the National Committee on Quality Assurance have released additional accreditations in the patient centeredness approach of the patient centered medical home. These new certifications continue those proposed by CCM and advance the work of these pioneers. Joint Commission’s Primary Care Medical Home looks at organizations that provide primary care medical services and bases its certification on elements that enable coordination of care and increase patient self-management. This is a model of care based directly on the foundational work provided by CCM. Additionally, CCM currently serves as a foundation for new models of primary care asserted by the American College of Physicians and the American Academy of Family Practice. In 2003, the ICIC program administrators convened a small panel of chronic care expert advisors and updated CCM to reflect advances in the field of chronic care from both the research literature and from the experiences of health care systems that implemented the model in their quality improvement activities. These programs were phased in during early June 2009. The asthma component sought to improve asthma care . Additionally, it had the objective of improving asthma outcomes .The objectives of the diabetes component of the program differed from the asthma module in that the program did not focus on the reduction of diabetes related deaths. Practice reviews did not identify diabetics as having an abnormally high mortality rate; however, improvements were sought in the numbers of hospitalizations and specialist treatment visits. While both chronic care conditions were intriguing areas of study for the program’s implementation, this paper focuses on the diabetic portion of the implementation because the earlier phase of asthmatic treatment did not result in sufficient data to enable proper analysis. During the preparatory stage of the Chronic Care Initiative , a not-for-profit consulting organization with correctional health care and learning collaborative experience was selected to assist the California Prison Health Care Services project team.

A statewide system assessment was conducted between January and April in 2008. Given the small window of opportunity under the federal receivership to accomplish the turnaround plan of action’s objectives, a very aggressive work plan and timeline was developed. To develop the work plan and identify potential problem areas, the team first established a list of limiting factors relevant to the operational environment. It was believed that in developing this list, the institutionalized nature of the organization and its key players could be catalogued. The factors could be utilized to address areas in which proactive focus and intervention efforts would be required in order to enable successful change on the part of long-tenured civil servants. The long-tenured employees were not capable of seeing all the flaws of their own routinized behavior because they had known no other ways. The theory under which the team operated was adopted from the above and related research on organizational change. Fernandez and Rainey discuss managing change once the change plan has been implemented and tasks are underway. To be innovative, the CCI team sought ways to stay ahead of the change curve and thus looked to capture variables of interest related to places where proposed change could get stuck by administrators unable to see how their usual behaviors and actions prevented successful change management. As a result, the plan that was developed included tasks specific to the implementation of the chronic care model in the health care setting. The team, in its proactive approach to implementation, identified aspects of organizational behavior that were important to track on the management side and designed methods to track and trend this behavior. Once tracked and trended, these data were used to develop interventions on managers to motivate their behavior in ways the team felt would enable the long-term success and sustainability of the changes at hand. Further, the catalog of behavior or aspects within the environment that were known to have likely deleterious effects on the proposed changes was used to redevelop the private sector chronic care model itself.

Revisions to the private-sector version of the chronic care model were necessary to fit the model for a custodial setting. With health care needs put behind those of security, the program architects found it necessary to modify and enhance aspects of the elements of the model. The first and perhaps least profound change was to the name of the program—to “Chronic Disease Management Program”—to avoid the perception that the inmate population would receive levels of care provision higher than enjoyed by the community at large because the program actually aimed to achieve a reduction in the cost of care while maintaining clinical efficacy of delivery and treatment. As a solely political move, it set the stage for the requirements of alterations to the rest of the model. Subsequent to discussions concerning the program’s name, each of the model’s standard elements were analyzed and repacked to fit the correctional environment. Due to the lack of learning collaborative and quality improvement information in the correctional health care literature, an innovative two-phase approach to implementation was developed. Phase 1 focused on piloting the learning collaborative strategy, developing a modified diabetes-change package for a correctional environment, and establishing the pilot sites to test the model. Phase 2 had the objectives of statewide implementation of the tested and approved approach from the pilot, while additionally moving on to the next chronic condition for the initial six pilot sites. After identifying the pilot sites,vertical farming the initiative began with intensive, multidisciplinary work sessions. Subsequent work sessions were performed using an enhanced learning collaborative strategy. Collaborative sessions were planned quarterly for the first year with teams from different sites attending four, two-day learning sessions separated by action periods. An intensive skills-based course on quality improvement was embedded into the learning sessions. Additionally, virtual learning workshops were inserted between the learning sessions to enable each collaborative to build workforce competencies on quality improvement technical skills. At the end of the learning sessions, pilot site teams folded into three regional learning collaboratives involving all 33 prisons to commence Phase 2 activities. The pilot-site champions served as presenters or mentors to the new sites during Phase 2, in a “train-the-trainer” approach. This approach required an initial round of training, and those trained during the first round were then deployed to train the rest of the staff. Figure 3 shows the culturally embedded barriers to implement CCM, as determined by the team. These obstacles are described in greater detail in the following section. They represent the targeted aspects of the model, which, due to their private-sector beginnings, would not fit into the custodial setting without modification. The re-adaptation of the model to fit the public sector, and more specifically the custodial environment within a public agency, was designed over several months, and its output was the subject of lively debate. The price for the program’s implementation failure was greater than the sum of its investment of time and resources. As many of the receiver-level clinical managers were brought into the receivership organization as employees of a new entity, results were expected. Because those expectations for results were high, the preparation for program implementation was carefully planned. It was understood that the receiver’s efforts were focused on remolding institutionalized patterns of action.

Initial efforts began with the breaking down of the six CCM elements into digestible tasks and deliverables within a project plan. A discussion then ensued concerning the parts of CCM that would not fit into the existing organization due to cultural barriers. Part of the debate mentioned earlier included the discussion among administrative staff with extensive CDCR experience, which provided insight about the barriers to a successful implementation in the custodial setting.A successful adoption of CCM is dependent on the visible support at all levels of the health care organization, starting with the senior managers. The federal receivership was established to provide the highest level of executive leadership support. The fiscal constraints of the state of California during the period of time when the program was implemented precluded the full adoption of CCM in the prison health care system. Clinical management that would otherwise have been dedicated to the coordinated care team was reduced. To increase managers’ visibility in relation to this program, attention was placed on coordination of care activities. This occurred at all levels, with headquarters-based administrative staff taking the lead in establishing the importance of the program by providing in-service trainings as well as on-site follow up support. In support of learning collaboratives, clinical administrators and supervisory staff were brought to headquarters facilities to participate in interactive sessions. It was felt that the overall effect of change in organizational behavior would occur once staff worked in collaboration to define new processes. To create visible leaders, managers had a role in shaping CCM implementation in a manner that was personally meaningful to them and would thus empower them. As the prison health care system is a single-payer, closed health care system, the potential to adopt evidence-based quality improvement strategies and practice guidelines is somewhat greater than would be the case in other health delivery settings. Because staff in a closed system is labor internal to the organization, the establishment of guidelines for these staff is an enabling factor for the full adoption of CCM policies with accountability for adherence to the model and results. The extent to which continuous, internally based labor learns and buys into the new policies and procedures equates to the extent to which sustainability of new methods can be achieved. In open health-delivery systems, clinical staff members are treated more as vendors than as internal staff. Because vendor relationships are managed differently than internal staff are, adherence to internal policies and procedures is more difficult to achieve. Some prisons institutionalized the use of temporary staff due to the relative ease with which these labor resources can be procured. Though temporary personnel cost was typically one and a half to two times the expense of a full-time employee, given the remote location of some facilities temporary staffing was preferred. This practice became institutionalized; as a supervising declared during interviews, “it was just the thing to do, because who has time to recruit and interview when using [temporary staff] was what everyone did.” She went on to note that “we certainly planned our staffing needs and secured the positions but look where we are . . . doctors can go [to the institution literally next door] and earn almost 25 percent more.