title: Challenges to implementing expanded team models: lessons from a centralised nurse-led cholesterol-lowering programme.
abstract: BACKGROUND
  Lowering low-density lipoprotein (LDL) cholesterol in patients with diabetes mellitus (DM) and cardiovascular disease (CVD) is critical to lowering morbidity and mortality. To increase the percentage of patients with DM and CVD at target LDL (<100 mg/dL), we launched an expanded team-based quality improvement programme in which centralised registered nurses (RNs) followed a detailed protocol to adjust cholesterol-lowering medications. Despite the growing use of team-based approaches to improve quality of care, little remains known about how best to implement them.
  
  
  RESULTS
  To share our experiences and lessons from operating a team-based programme, we conducted a retrospective observational analysis of administrative and clinical data on programme performance. We measured: primary care physician (PCP) and patient acceptance of the programme, number of medication adjustments, change in LDL, per cent of patients achieving target, time to LDL target and the efforts required to achieve these goals.
  
  
  RESULTS
  Using administrative data, we initially identified 374 potential patients for enrolment. Chart review revealed that 203 (54%) were clinically eligible. PCPs agreed to enrol 74% (150/203) of these patients. Thirty-six per cent of PCP-approved patients (54/150) could not be reached via phone and 5.3% (8/150) declined enrolment. Of patients enrolled (n=64), 50% did not complete the programme. Of those enrolled, median LDL decreased by 21 mg/dL and 52% (33/64) achieved the LDL target. Programme RNs spent 12 023 min on programme activities, of which 44.4% (5539) was related to non-enrolled patients.
  
  
  CONCLUSIONS
  Our adoption of a centralised expanded team-based programme for the management of LDL cholesterol uncovered many barriers to efficiency and success. Even though expanded team programmes may be supported by PCPs, the administrative efforts required to identify, enrol and continually engage eligible patients raise many concerns regarding efficiency and highlight infrastructure changes needed for successful team-based approaches.
authors.affiliation: Brigham and Women's Physicians Organization, , Boston, Massachusetts, USA.
authors.forename: Emily K
authors.initials: EK
authors.lastname: Kadehjian
authors.forename: Louise
authors.initials: L
authors.lastname: Schneider
authors.forename: Jeffrey O
authors.initials: JO
authors.lastname: Greenberg
authors.forename: Jessica
authors.initials: J
authors.lastname: Dudley
authors.forename: Allen
authors.initials: A
authors.lastname: Kachalia
mesh_terms: D000328:Adult; D000368:Aged; D000924:Anticholesteremic Agents / Q000627:therapeutic use; D002318:Cardiovascular Diseases; D008078:Cholesterol, LDL / Q000097:blood; D003920:Diabetes Mellitus / Q000097:blood; D005260:Female; D006801:Humans; D006937:Hypercholesterolemia / Q000188:drug therapy / Q000451:nursing*; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning; D010348:Patient Care Team / Q000458:organization & administration* / Q000592:standards; D016730:Program Development; D015397:Program Evaluation; D012189:Retrospective Studies
chemical_list: D000924:Anticholesteremic Agents; D008078:Cholesterol, LDL
keywords: Chronic Disease Management; Diabetes Mellitus; Nurses; Quality Improvement; Teams