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The Collaborative process utilizes three models:

 

The Care Model:

The Care Model emphasizes evidence-based, planned and integrative collaborative chronic care. This population-based model creates practical and supportive interactions between an informed, active patient and a prepared, proactive practice team. The Care Model encompasses six elements, or change concepts:

• Health Care Organization
• Community Resources and Policies
• Self-Management Support
• Decision Support
• Delivery System Design
• Clinical Information Systems

 

The Improvement Model:

 

The Improvement Model is applied to the Care Model to provide a process to improve the quality of care at an accelerated pace. The model applies knowledge through rapid testing of changes in practice. The Improvement Model is based on three fundamental questions:

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?

 

The Learning Model:

The Learning Model is the 12 months of intensive learning that occurs in Phase I - the implementation phase of a Collaborative. The Learning Model is adapted from the Institute for Health Care Improvement’s Breakthrough Series. The following are phases of the learning model.

1.  Health center leadership selects the staff team that will work on the Collaborative.
2. The team does initial Pre-work to gain an understanding of the Collaborative and the issue being studied, which may be Asthma, Cancer, Cardiovascular Disease, Depression, Diabetes, Diabetes Prevention, Prevention or Finance/Redesign.
3. The team participates in four Learning Sessions with teams from other centers and with expert advisors. At these sessions, change ideas and results are shared among all teams.
4. Between each Learning Session is an Action Period, during which each center develops, tests, and trial runs for their change idea, using the PDSA model (described below under Improvement Model).
5. After the final Learning Session, each center works on ways to move the new model into other clinic areas or other sites.

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