Residents, Staff, and Patients Working as a Team
A key aspect of the Chronic Care
is developing a multidisciplinary team to deliver patient care.
A range of skills from various specialties working together
enhances interactions between patients and the care team. Openness to
collaborating with the patient, redefining clinical and non-clinical roles in
the care continuum, and building new team structures
are significant in implementing the Chronic Care Model.
To assess its strengths and weaknesses, the Hoxworth
internal medicine-pediatric team at the University of Cincinnati Academic
Health Center conducted a Team Health Audit and identified several barriers
to successful team functioning.
The Oregon Health & Science University team redesigned
its doctor-centered practice model to a multidisciplinary care team that
- Faculty physicians (general internists).
- A chief medical resident.
- Residents in internal medicine.
- A registered nurse.
- A social worker.
- Medical assistants.
The Oregon Health & Science University team also identified three factors
that defined their team-building efforts:
regular patient-care team meetings in the practice where team members work.
the team with shared responsibility.
The Summa Health System Change Team positioned the nurse
practitioner as the collaborative care manager.
A complete job description
detailing the qualifications and responsibilities for the nurse practitioner
collaborative care manager is available for download.
The Planned Visit Notebook
Summa's Family Medicine team also developed a Diabetes Planned Visit Notebook.
The notebook provides a step-by-step description for the
planned visit, including priorities for care. Everything needed to conduct the
planned visit is included in the notebook. Examples of the kinds of materials
included within the notebook zipfile include:
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