Residents, Staff, and Patients Working as a Team

Toolkit for Implementing the Chronic Care Model in an Academic Environment

A key aspect of the Chronic Care Model  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.

Team Building

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 included:

• 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:

1. Holding regular patient-care team meetings in the practice where team members work.
2. Empowering the team with shared responsibility.
3. Building trust.

Redefining Roles

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:

• Algorithms: Glycemic Control (DM1), Glycemic Control (DM2), Lipid Lowering, Hypertension.
• Setting a Self-Management Goal sheet.
• Fact Sheets: Smoking, Safe and Healthy Exercise, Oral Diabetes Medications, Steps to Healthy Feet, High Blood Pressure.

Tools:

• Team Health Audit Questionnaire
• Barriers
• Collaborative Care Manager Model
• Nurse Practitioner Job Description
• Diabetes Planned Visit Notebook
• Glycemic Control (DM1) Algorithm
• Glycemic Control (DM2) Algorithm
• Lipid Lowering Algorithm
• Hypertension Algorithm
• Setting a Self-Management Goal sheet
• Smoking Fact Sheet
• Safe and Healthy Exercise Fact Sheet
• Oral Diabetes Medications Fact Sheet
• Steps to Healthy Feet Fact Sheet
• High Blood Pressure Fact Sheet