Chronic Care Collaborative


In 2008, the CCE managed N.C. Children’s Chronic Care Collaborative, a group of 6 pediatric clinic teams that aim to improve chronic disease outcomes and affect organizational change in the Children’s Hospital. The teams focus on airway disorders, asthma, cystic fibrosis, chronic kidney disease, diabetes, and inflammatory bowel disease (IBD).

Using the Model for Improvement and the Chronic Care Model, the teams have made the following improvements:

  • decreased the percentage of pediatric IBD patients with active disease
  • increased documentation of steroid status, growth and nutrition classification, and disease activity for pediatric IBD patients
  • increased the percentage of pediatric cystic fibrosis patients classified with optimal nutrition
  • decreased the percentage of pediatric cystic fibrosis patients in nutritional failure
  • decreased hospitalizations for pediatric diabetic patients on insulin pumps
  • increased use of patient registries to track patients and plan visits


The teams also encourage families and patients to actively participate in individual heath care plan and changes to the clinic.