title: Understanding effective care management implementation in primary care: a macrocognition perspective analysis.
abstract: BACKGROUND
  Care management in primary care can be effective in helping patients with chronic disease improve their health status. Primary care practices, however, are often challenged with its implementation. Incorporating care management involves more than a simple physical process redesign to existing clinical care routines. It involves changes to who is working with patients, and consequently such things as who is making decisions, who is sharing patient information, and how. Studying the range of such changes in "knowledge work" during implementation requires a perspective and tools designed to do so. We used the macrocognition perspective, which is designed to understand how individuals think in dynamic, messy real-world environments such as care management implementation. To do so, we used cognitive task analysis to understand implementation in terms of such thinking as decision making, knowledge, and communication.
  
  
  METHODS
  Data collection involved semi-structured interviews and observations at baseline and at approximately 9 months into implementation at five practices in one physician-owned administratively connected group of practices in the state of Michigan, USA. Practices were intervention participants in a larger trial of chronic care model implementation. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with macrocognition as a guiding framework.
  
  
  RESULTS
  Seventy-four interviews and five observations were completed. There were differences in implementation success across the practices, and these differences in implementation success were well explained by macrocognition. Practices that used more macrocognition functions and used them more often were also more successful in care management implementation.
  
  
  CONCLUSIONS
  Although care management can introduce many new changes into the delivery of primary care clinical practice, implementing it successfully as a new complex intervention is possible. Macrocognition is a useful perspective for illuminating the elements that facilitate new complex interventions with a view to addressing them during implementation planning.
authors: Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E 17th Avenue, Mail Stop F496, Room 3505 Academic Office 1, Aurora, CO, 80045, USA. Jodi.holtrop@ucdenver.edu.
authors: Jodi Summers
authors: JS
authors: Holtrop
authors: Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, Albany, NY, USA.
authors: Georges
authors: G
authors: Potworowski
authors: Department of Family Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
authors: Laurie
authors: L
authors: Fitzpatrick
authors: Priority Health, Grand Rapids, MI, USA.
authors: Amy
authors: A
authors: Kowalk
authors: Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors: Lee A
authors: LA
authors: Green
mesh_terms: D000066491:Clinical Decision-Making; D003071:Cognition; D006801:Humans; D007407:Interviews as Topic; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D016730:Program Development