Academic Chronic Care Collaborative

Academic Chronic Care Collaborative

The Academic Chronic Care Collaborative (ACCC) is a partnership between the Association of American Medical Colleges (AAMC) and Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation.


One hundred million Americans suffer from chronic conditions. Eighty percent of Medicare recipients have one or more chronic illnesses, a resource burden that amounts to the overwhelming majority of Medicare expenditures. Despite the personal burden of illness and the strain on community resources, many deficiencies remain in the current management of chronic conditions. They include lack of care coordination, hurried practitioners, inadequate use of effective treatments, lack of systematic follow-up to ensure the best outcomes, and patients who are inadequately prepared to manage their own illnesses.

Overcoming these deficiencies requires a transformation of healthcare from a system that is essentially reactive—responding mainly when a patient is sick—to one that is proactive and focused on keeping a person as healthy and functional as possible. To speed this transformation, Dr. Ed Wagner and his colleagues have organized proven approaches to better, more effective care in the Chronic Care Model. This model has guided improvement efforts in hundreds of care settings including the US Department of Veteran's Affairs, Community Health Centers, Kaiser Permanente, and other leading health systems. Nevertheless, few of these have been academic settings with integral involvement of residents and other health professions students.


The AAMC Institute for Improving Clinical Care has embarked on a partnership with the Improving Chronic Illness Care Program to offer a collaborative initiative to facilitate adoption of the Chronic Care Model in academic settings. This strategy links the organizational resources of the AAMC with the expertise of Wagner's Improving Chronic Illness Care Program to launch the Academic Chronic Care Collaborative.

The Collaborative is anchored in the rationale that health professions students and residents should learn in settings that strive always to deliver the highest standard of care achievable. The initiative will employ the Breakthrough Series Collaborative learning model developed by the Institute for Healthcare Improvement (IHI).

Teams will be assembled from a group of academic centers that are prepared to implement change in the care of one or more selected chronic conditions. Teams are encouraged to focus on a condition where the Model has been implemented effectively. Examples of such conditions include diabetes, asthma, congestive heart failure, chronic arthritis, and depression.

The Academic Chronic Care Collaborative will take place over an 18-month period during which multi-disciplinary teams will attend a Kick-off Session, two face-to-face interactive Learning Sessions (I and III), a virtual Learning Session (II), and a Congress that will coincide with the Association of American Medical Colleges Annual Meeting. During the "Action Periods" between each Learning Session, the teams will implement what was learned, assess what changes worked, and devise alternative strategies where needed. During that time the teams will have access to expert advice and troubleshooting, resources, and an opportunity to exchange ideas and information with other collaborative participants through conference calls and an email listserv.

Collaborative Goal

The goal of this collaborative is to improve the care of patients with chronic illness and the education of the health care teams providing the care in academic settings by implementing the Chronic Care Model.


Improving Chronic Illness Care (ICIC) and the Association of American Medical Colleges (AAMC) Planning Committee will:

  • Provide evidence-based information on the subject matter, application of that subject matter and methods for process improvement, both during and between Learning Sessions

  • Build on what has already been developed in the US and use the best change packages and methodology available.

  • Provide monthly report written feedback to pilot teams and offer coaching to organizations.

  • Provide communication strategies to keep offices connected to the Planning Committee and colleagues during the Collaborative.

  • Provide faculty that are experienced in population management to enhance learning.

Participating physician practices offices are expected to:

  • Be open to changing actions and system in order to improve clinical management and office efficiency.

  • Perform pre-work activities to prepare for the Kick-off Session

  • Provide a lead physician who will champion the testing and spread of changes in the practice environment, and will attend all Learning Sessions.

  • Send a team from the practice to all Learning Sessions.

  • Provide their team time to devote to testing and implementing changes in the practice.

  • Test changes that lead to the implementation of the Chronic Care Model and produce change in their practice.

  • Use a practice-based patient registry to monitor and report population outcomes (i.e. diabetes measures) on a monthly basis.

  • Submit monthly progress reports that include all the measures that your team is using to monitor progress.

  • Share information with the Collaborative, including details of changes made, and data to support these changes, both during and between Learning Sessions and for the Closing Congress.

We will strive to meet the Collaborative goals within 18 months by sharing ideas and knowledge, learning and applying a methodology for organizational change, implementing a chronic disease management model and a resident educational model practice-wide, and measuring progress in population outcomes and educational outcomes.

Listed below are our partners, the chronic illness care element(s) that they address, and contact information for each.

UofL Hospital Pharmacy Department
PharmD Residency Education Program

  • Health System

  • Decision Support

  • Delivery System Design

Jessie Morgan, PharmD
(502) 562-6742

Tina Claypool
(502) 813-6105

UofL Hospital Diabetes Care Coordination

  • Inpatient Service Only

Sue McGowan, NP, ADM (502) 562-4308

Tammy Grider, MSN, CDE
(502) 562-3203

Passport Health Plan

  • Health System

PHP Disease Management Team
(502) 585-8361

Becky Barbera
Health Management Supervisor
(502) 213-8903

Kentucky Diabetes Network (KDN)

  • Community Resources

  • Self-Management Support

  • Decision Support

Reita Jones
(502) 564-7996 x4443

Theresa Renn
(502) 564-7996 x4442

Louisville Metro Department of Public Health & Wellness,
Health Education and Promotion

  • Community Resources
  • Diabetes Education
  • Stop Smoking Classes

Leanne French, MS Administrator
(502) 574-6663

Metro YMCA

  • Community Resources

Steve Tarver, CEO

Alison Tyler, PR

(502) 587-9622

DocSite Patient Planner Registry

  • Decision Support

  • Clinical Information Systems

  • Delivery System Design

  • Self-Management Support

Anne Banks

(502) 852-3857

Family Medicine Team
Group Visits •Planned Visits •Nutrition Counseling •Integrated Mental Health

  • Delivery System Design

Susanne Steinbock, NP

Nancy Kuppersmith, RD, MS, CDE

Anne Mason, LMFT

Patty Webber, Chronic Care Nurse