Chronic Disease Improvement

Chronic disease care quality improvement is a key initiative of the Foundation.  In 2007, under the leadership of Kurt Elward, MD, MPH, the Foundation created TO GOAL: Together Obtaining Guidelines Optimization, Adherence and Lifestyles, a physician-driven approach to clinical care quality improvement.  This program optimizes the American Board of Family Medicine’s (ABFM) recertification process by implementing a practice-wide approach that allows for self-identification of opportunities for systems improvement and patient adherence while providing physicians the opportunity to prepare for pay-for-performance on physician terms. 

Fundamentals of the Chronic Care Model were used in the development of TO GOAL and therefore it employs several major strategies to: 

1. Improve physician identification of at-risk patients; and
2. Provide physicians with the tools and resources needed to ensure that their patients adhere to necessary treatment protocols and comply with recommended practice guidelines.

Foundation Quality Improvement Initiatives:

TO GOAL Phase I: Cardiovascular disease - 2007-2008
The program achieved its objectives by utilizing expert physician and clinical faculty to guide physician participants in identifying best practices in care; developing achievable plans for integrating these practices into clinical care; and providing tools and technical assistance for plan implementation.  Nearly 100 participating physicians evaluated their patients’ records, in collaboration with their partner physicians and clinical staff, to identify opportunities to meet or exceed guidelines for identification and treatment of patients at-risk for coronary artery disease and hypertension. 
    
IMPACT: Improving Asthma Care and Treatment - 2008-2010
The current program utilizes the successful model developed in TO GOAL to provide asthma quality improvement guidance, support and resources.  Elements of the Patient Centered Medical Home (PCMH) will be reinforced throughout the program, providing teams with an introduction to the fundamentals of this model of care.  Nurse team members will be further engaged throughout the IMPACT process and will be offered asthma education through the National Respiratory Training Center and American Lung Association's Asthma Educator Institute.  
        Participating teams represent: Central Virginia Family Physicians, Tidewater Physicians Multispecialty Group, and Sentara Medical Group.
        Key faculty: Kurt Elward, MD, MPH; Mark Greenawald, MD; Steve Horan, PhD; Daniel Longo, ScD; and Helen Ragazzi, MD.

For more information about the Foundation's quality improvement initiatives, please contact:

Ashley Cunningham, Director of Programs, Phone: 804 | 377-1047