Background: A recent cross-sectional study of 6700 Americans found that patients with chronic illnesses receive only half of the recommended care.1 Wagner et. al. developed a Chronic Care Model (CCM) to improve care of chronic disease, particularly congestive heart failure, asthma and diabetes.2 The CCM multidisciplinary approach combines community resources, patient self-management support, and clinical information systems. At the Rhode Island Hospital resident clinic (MPCU) we care for 800 patients with type II diabetes. Chronic disease management is challenging in our setting because of socioeconomic barriers, multiple providers, and large numbers of active medical problems. However, clinics similar to ours have improved their treatment of chronic disease using a CCM.

Methods: We created a pilot CCM program to improve treatment of type II diabetes at the MPCU. Ninety-nine patients, identified using ICD-9 codes and resident input, were enrolled in a computerized registry. After each visit, data were updated and a printed summary report was placed in the chart. The reports graphically depict trends in lab values and designate care that is due in a bold font. We educated residents about the program at a noon-conference lecture, in small groups, and via electronic mail. Patients were given educational and self-management materials and received a printed report at each visit. If overdue for an appointment, they were called and rescheduled. The pilot program continued for 6 months.

Results: At baseline, 30% of patients had a HgA1C of less than 7% and 54% met cholesterol treatment guidelines. These values did not significantly change over the course of this intervention but the number of patients who had these labs checked increased. Other parameters of care improved. Diabetic education increased from 14% to 23% and nutritional education from 8% to 16%. Documented foot exams improved from 33% to 38%. The number of patients on an ACE-I or ARB increased from 76% to 90% and the number of patients on aspirin went from 42% to 50%. The retinal exam rate did not change.