The Chronic Conditions Care Collaborative (4C Collaborative): A Platform for Improving Diabetes and Heart Disease Outcomes in Rural South Carolina

Abstract

Rural U.S. counties experience racial, geographic, and socioeconomic disparities in chronic diseases. Collaborations among stakeholders in rural areas are needed to make measurable changes in health care outcomes in South Carolina. The Chronic Conditions Care Collaborative (4C Collaborative) was developed to provide an opportunity for health care teams in medically underserved areas of South Carolina to convene to improve diabetes and heart disease outcomes. The 4C Collaborative was a quality improvement (QI) learning collaborative focused on the identification of patients with undiagnosed hypertension, team-based care through medication therapy management (MTM), and diabetes management. All QI work was approached through a health equity lens. Fifteen medical practices across two cohorts participated in the 4C Collaborative and gained access to more than 35 hours of educational content and guided action steps to create systemic changes specific to the needs of their patient population. Participation also conferred access to one-on-one technical assistance with faculty subject-matter experts. The activities within the 4C Collaborative allowed health care practices to identify areas of improvement within their practices and test improvement strategies through Plan-Do-Study-Act (PDSA) cycles. Best practices and lessons learned from learning collaborative participants were compiled into storyboards and presented during end of program celebrations.