Caribbean Chronic Care Collaborative (CCCC)Implementation Manual for Collaborative Projects to Improve the Quality of Care for People with Chronic Diseases
About This Manual

The purpose of this manual is to provide users with information from references on collaborative projects. The manual is also designed to help ensure successful initial preparations for the year of work on this project, whose aim is to improve the quality of life of people with chronic diseases.

  • The first part, Theoretical Framework for Collaborative Projects, contains an overview on the Collaborative and its theoretical framework, with a proposed timeline for the most important events and activities.
  • The section Activities in the Preparatory Stage of the Collaborative gives a step-by-step description of the development of the project and organization of the participants, along with tools to establish the baseline that will be used to measure the impact of the project.
  • The section Operational Stage of the Collaborative details step by step the main activities of the Learning Sessions and Action Periods.
  • Finally, the Annexes contain the VICEN assessment and ACIC instruments, sample indicators, agendas, and model change packages.

CARIDIABImproving Care to Change Lives


In Latin America, an estimated 13.3 million people had diabetes in the year 2000, a figure that is projected to increase by 2030 to 32.9 million, or double the number of cases. The estimates indicate that the diabetes epidemic will persist, even if the prevalence of obesity remains at current levels until 2030. The doubling of case numbers will occur as a simple consequence of population aging and urbanization. However, given the increase observed in the prevalence of obesity in many countries around the world and its importance as a risk factor for diabetes, the number of diabetes cases in 2030 could be much higher.1

The increase in the prevalence of diabetes in the United States has been explained by a similar increase in the proportion of obese people, rather than an absolute increase in the risk of developing diabetes.2 According to the CAMDI survey of people aged 20 and over in Central America, the prevalence was higher in Belize (12.4%), Nicaragua (9.01%), and Guatemala (8.23); intermediate in Costa Rica (7.9%) and El Salvador (7.4%); and lower in Honduras (6.1%).

Diabetes is often diagnosed late. Various research projects indicate that 50% of all patients with type 2 diabetes present with some type of cardiovascular complication at the time of their diagnosis. The most significant complications (micro- or macrovascular) are retinopathy, with percentages ranging from 10% to 30%; neuropathy, 8% to 33%; and impotence, 35% to 66%, with hypertension ranging from 32% to 65%. Diabetes is the most common cause of polyneuropathy, and roughly 50% of people with diabetes mellitus experience neuropathic alterations in the 25 years following diagnosis. Diabetes is responsible for about 90% of all nontraumatic amputations and the leading cause of terminal renal insufficiency.

The QUALIDIAB study conducted in clinics in the capital cities of Central America showed that people with diabetes treated in these centers did not achieve adequate glycemic control.

The proportion of patients with good glycemic control varied, with higher percentages in Nicaragua and Costa Rica and lower percentages in Guatemala and Honduras. Numerous incomplete clinical files were found, which made it impossible to adequately assess patient care. Preventive practices, such as nutrition education and physical activity, were deficient.

Improving treatment for diabetes and other chronic diseases should be a priority in medical practice in Central America, since some 6% to 9% of all adults suffer from this disease and projections point to a sharp increase in the near future.

One strategy for improving the quality of care for people with diabetes is to develop and implement a collaborative project for countries or health services interested in launching projects for continuous improvement of the quality of care, based on the Breakthrough Series (BTS) model proposed by Boston's Institute for Healthcare Improvement—-a model that has proven effective in hundreds of initiatives in the United States, Canada, and many other countries around the world.

The objective of the Collaborative Project is ongoing improvement of the quality of care for people with chronic diseases through a joint effort by professionals and health managers to ensure excellent practices in health units or services. For approximately one year, managers, health professionals, and people with chronic diseases should come together in Learning Sessions (three in all) to participate in training, planning, and evaluation activities. During these Learning Sessions, the participants from the health units/services will work on evaluating their services and prepare an intervention plan based on the proposed change package, stating the activities programmed for the action periods. The commitment of each team to producing these plans is important for improving outcomes.

The methodology has already been used in several of countries and has permitted lasting change once it leads to a change in mentality and a joint effort by each and every health team, with the commitment of each professional.

PAHO's experience in the implementation of this type of project in Mexico was positive.

Through this manual, it now hopes to arouse enthusiasm in other countries with similar projects.


1 Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27(5):1047-1053

2 Gregg EW, Cadwell BL, Cheng YJ, Cowie CC, Williams DE, Geiss L, et al. Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the US. Diabetes Care 2004;27:2806-2812.