Chronic Illness Management in Teams of Urban Multidisciplinary Scholars: CIMTUMS

Aurora Affiliations

Academic Affairs, Aurora UW Medical Group, Department of Family Medicine

Presentation Notes

Presented at 2014 Aurora Scientific Day, Milwaukee, WI


Background: Patients with chronic illness benefit from health care that addresses diverse health needs through multiple disciplines. At Aurora Midtown Clinic, CIMTUMS used interprofessional teams of students and faculty working with African American diabetic patients to improve selfmanagement skills and diabetes biomarkers. The first two cycles demonstrated a high level of patient participation and successful collaboration between Aurora Health Care, University of Wisconsin School of Medical and Public Health and Concordia University. The multidisciplinary health care team consists of a physician, pharmacist, dietitian, nurse practitioner and exercise physiologist with medical, pharmacy and biology students.

Purpose: Simultaneous multidisciplinary delivery of care can improve health outcomes and self-management skills in chronic diabetic patients.

Methods: Phase 1: The interdisciplinary team met four times for team-building activities that focus on patient centered delivery of care, leadership, and cross-discipline communication. They used CDC’s TeamSTEPPS and its questionnaire to evaluate baseline knowledge and attitudes towards cross-collaboration. Phase 2: Patients were recruited from a pooled list of those meeting eligibility using established biometrical control norms (hemoglobin > 7, blood pressure > 130/80, low-density lipoprotein > 100). Patients participated in five sessions using the American Diabetes Association Self-Management and Education program and Merck conversation maps. Phase 3: Coaching and follow-up of patients occurred via phone to assist patients in meeting their personal goals. The health team identified needs and barriers to compliance and ensured sustainability of learned concepts.

Results: Results from the initial two cycles include significant learner attitude and behavior changes as well as improvement in diabetic patients’ biomarkers, empowerment and satisfaction. Results from the third cohort are pending.

Conclusion: An interdisciplinary team approach to chronic disease management maximizes the possibility for improved health outcomes in patients. Patient self-efficacy is increased by shared input and knowledge from peers and the health care team. Interdisciplinary team members work together to enhance their knowledge and skills for a comprehensive and patient-centered approach. CIMTUMS success with diabetes management demonstrates the potential for application to other chronic health issues such as hypertension or asthma.

Document Type


Link to Full Text