Rhode Island Chronic Care Collaborative

The gap between what is possible in the care of chronic illness and the reality of the care currently being delivered has been the driving force behind the creation and evolution of the Rhode Island Chronic Care Collaborative. Evidence associating morbidity and mortality with chronic illness motivates us to strive to narrow and eventually close the gap, thereby improving the quality of healthcare delivery with the possibility of lowering overall costs.


In 1999, the Rhode Island Chronic Care Collaborative grew out of a partnering of the Rhode Island Department of Health Diabetes Prevention & Control Program and the Thundermist Health Center in the Bureau of Primary Health Care Health Disparities Collaborative for diabetes. Between 2000 and 2002 the Diabetes Prevention and Control Program created an in state collaborative with the addition of ten community health centers and one hospital-based practice. In 2003 the Diabetes Prevention and Control Program and Quality Partners of Rhode Island (now Healthcentric Advisors received a grant from the Robert Wood Johnson Foundation’s Improving Chronic Illness Care program to train physician practice teams based on the Bureau’s Collaborative model. The RICCC has continued to use the Learning Model from the Institute for Healthcare Improvement to train participating teams in the implementation of the Chronic Care and Improvement Models.

The Chronic Care Model was developed from work started in 1993 by Ed Wagner, MD of the MacColl Institute for Healthcare Innovation. The Improvement Model is based on the work of Shewart and Deming and is used to facilitate small scale, rapid cycle testing of innovations. These models include Learning Sessions throughout the year, monthly conference calls and progress reporting, networking to learn from each other, and the use of the Plan, Do, Study, Act methodology to test practice changes before they are finalized.

The Outcomes Congress, held at the end of each collaborative year, affords an opportunity for the RICCC and its group of current first year teams and past years’ sustaining teams to showcase their accomplishments. Continuing in the collaborative after the initial year of learning, changing, and improving is a goal, and as such Rhode Island Chronic Care Collaborative is proud that at the 2007 Congress almost all current and sustaining teams are participating.

What We Do

  • Provide technical assistance to participating physician practices as they move towards becoming patient-centered medical homes;
  • Assist practices in embedding standards of care for diabetes;
  • Assist in the establishment of standards for patient-centered medical home in Rhode Island.