CliniCal PraCtiCe imProvement

Chronic diseases place a substantial burden on the health of affected individuals as well as on society. More than 90 million people in the United States are living with chronic diseases, and more than 75% of U.S. medical care costs are spent caring for them [1]. The toll on human life is also significant, with chronic diseases accounting for 70% of all deaths and one third of the years of potential life lost before age 65 years [1]. Addressing the burden of chronic disease is a complex challenge faced by every health care organization. The current medical system is designed to respond to acute care problems, and the urgent need to address acute health concerns prevails over the less urgent need to manage chronic illness effectively [2]. Optimal chronic disease management requires planned, regular interactions between patients and their caregivers, with a focus on maintaining and/or improving function and preventing disease exacerbations and complications, needs that are unlikely to be met by a health care system and culture geared to respond to acute care problems [3]. The chronic care model evolved out of an interest at the Group Health Cooperative in Seattle, WA, to correct health system deficiencies undermining the optimal care of patients with chronic illness [2–4]. The model was based on literature review and suggestions from experts at Group Health’s MacColl Institute for Healthcare Innovation. According to the chronic care model, optimal care for chronic illness is achieved when a prepared, proactive clinical practice team interacts with an informed, activated patient [3–5]. The model identifies 6 essential components that comprise a system geared to provide such care (Figure 1): community resources and policies, organization of health care, self-management support, delivery system design, decision support, and clinical information systems. The chronic care model proposes a new chronic disease paradigm: a physicianpatient relationship based in collaborative care with an emphasis on self-management. The model has been implemented in a variety of nonacademic clinical settings, with significant success. Premier Health Partners (Dayton, OH) implemented the model in its 36 office practices to improve diabetes care and 3 years later reported an increase from 42% to 70% in the proportion of patients with a glycosylated hemoglobin (HbA1c) level less than 7% [5]. Similarly, HealthPartners Medical Group (Minneapolis, MN), using 4 components of the chronic care model over 1 year, improved the percentage of patients with an HbA1c level less than 8% from 60.5% to 68.3% [5]. In 2005, an initiative to foster adoption of the chronic care model in academic settings was launched by the Association of American Medical Colleges Institute for Improving Clinical Care (www.aamc. org/iicc) in partnership with the Improving Chronic Illness Care program of the Robert Wood Johnson Foundation (www.improvingchroniccare.org). The major goals of the Academic Chronic Care Collaborative (ACCC) are to improve the care of chronically ill patients who receive their care at an academic medical center and to ensure that clinical education associated with chronic illness care occurs in an exemplary environment. Southern Illinois University (SIU) is one of 22 academic medical centers involved in this initiative. Clinical practice teams from the division of general internal medicine (GIM), the department of family and community medicine, and the division of rheumatology are involved. The goal of the GIM team in the ACCC project is to redesign the care provided to patients with type 2 diabetes using the components of the chronic care model and to integrate the concepts of the chronic care model into resident education and practice. This article reports the experience of 3 internal medicine residents who participated on the GIM team in the pilot phase of the ACCC project at SIU. As previously reported in Seminars in Medical Practice, secondand third-year internal medicine residents at SIU are required to have 8 months of hands-on participation in a quality improvement (QI) project [6], and working on the GIM pilot team satisfied this requirement. In this article, the contributions of the 3 pilot