Chronic Care Model Elements | Fidelity of the CHAPS Model Components to the Chronic Care Model [7] | Fidelity of CHAPS Implementation of CHAPS Model [14] to Hasson’s Model |
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Health System Resources and Policies | ||
5 Veterans Affairs Healthcare Systems medical centers | Greater Los Angeles, Las Vegas, Loma Linda, Long Beach, San Diego (Content) | |
Community Resources and Policies | ||
Local/regional/national organizations and services (local APDA, LA-CRC, NPF, and PRO; and other local Parkinson’s disease support groups) | Recommended use of community services (n = 78, 29.5% of all service referrals) (Content) (Frequency) | |
Delivery System Redesign | ||
CHAPS nurse care managers | 8 nurses hired and oriented to deliver CHAPS care management (Content) | |
Parkinson’s disease specialist and CHAPS nurse care manager regularly scheduled huddles | CHAPS nurse care managers reported to principal investigator that huddles occurred monthly (Content) (Frequency) | |
Telephone encounters with participants | n = 656 telephone encounter notes abstracted | |
• n = 68 (prior to Initial CHAPS Assessments) | ||
➢ Initial CHAPS Assessments | • n = 140 (Initial CHAPS Assessments) | |
➢ Follow-up calls | • n = 317 (~ 3 follow-ups per participant) a | |
➢ 6-month reassessments | • n = 67 (6-month reassessment, for 50% of eligible candidates | |
➢ Annual reassessments | • n = 29 (Annual reassessment, for 23% of eligible candidates) | |
• n = 35 (2nd 6-month reassessment at 18-months for 29% of eligible candidates) (Frequency – partial fidelity) (Duration) | ||
Siebens Domain Management Model™ (SDMM™) b as the organizing framework | Domain headings used in documentation of 4870 (97.7%) of CHAPS problems/topics. These distributed over the 4 domains: • Domain I 38.8% • Domain II 27.5% • Domain III 14.3% • Domain IV 19.4% (Content) (Frequency) | |
Siebens Health Care Notebook [18] | • Personalized self-care tool sent to each participant (n = 140) c • Notebook discussed with participants n = 108 (77.1%) (Content) (Frequency) | |
Decision Support | ||
31 standard CHAPS problems/topics identified through algorithms | Problems/topic types were documented (n = 4938) (Content) (Frequency) | |
CHAPS problem/topic intervention protocols with care recommendations d | CHAPS nurse care manager activities (n = 4012) (27 types) (Content) (Frequency) | |
CHAPS nurse care manager meetings | Meetings twice a month for mutual support and clinical problem-solving (Content) (Frequency) | |
Decision support provided by Parkinson’s disease specialists directly to CHAPS nurse care managers through huddles | CHAPS nurse care managers reported to principal investigator huddles occurred monthly (Content) (Frequency) | |
Clinical Information Systems | ||
Computerized Patient Record System - CPRS (Veterans Affairs electronic medical record for inpatient and outpatient services) | CHAPS nurse care manager notes (n = 656) (Content) (Frequency) | |
CHAPS structured Initial Assessment with algorithm-identified CHAPS standard problems/topics in Microsoft Access | CHAPS Assessments (n = 140) and problems/topics identified (Content) (Frequency) | |
Participant panel tracking tool in Microsoft Access | Tool cumbersome and discontinued; alternative secure methods used (Content) | |
Self-management Support | ||
Prioritizing problems/topics with participant input | Most frequent concerns: • medications (n = 58 participants) • physical activity (n = 49 participants) • falls (n = 49 participants) (Content) (Frequency) | |
Coaching by nurse care managers | • Education: verbal (n = 310), print (n = 168), Internet or DVD (n = 68) notes • Counseling and emotional support (n = 387 notes) • Motivational collaborative-problem solving (n = 144 notes) (Content) (Frequency) | |
Siebens Health Care Notebook | • Participants (n = 83, 59.3%) interacted with Notebook • Problem-focused education sheets (n = 2.6 (SD 2.4)) added from 69 unique education sheets (Content) (Frequency) | |
My HealtheVet (online tool for partnering with health care team with secure messaging) | Referral to My HealtheVet patient portal (n = 23 notes) (Content) (Frequency) |