Toolkit for Implementing the Chronic Care Model in an Academic Environment
Diabetes Planned Visits-University of Cincinnati Academic Health Center
Each of the four pilot sites adapted the basic concepts underlying the planned visit approach to meet the unique needs of the team and patient population. The University of Cincinnati Academic Health Center's Hoxworth internal medicine-pediatric team's approach follows.
Diabetes Planned Visits
University of Cincinnati Academic Health Center
Hoxworth Internal Medicine-Pediatric Team
The Hoxworth internal medicine-pediatric team developed a clinical diabetes visit process for individual patients as well as one for group visits.
The process for individual visits was applied to all the patients with diabetes in the population of focus, regardless of their chief complaint. The basic procedure used the encounter form, flow sheet, and Smart Goal sheet:
- Before the visit, front office staff:
- Identifies the diabetic patients' charts, which are tagged with an orange sticker with a "D" on it.
- Prints an encounter form, highlighting missing info.
- Puts flow sheet and self-management sheets on chart.
- During the visit, the nurse, medical assistant, or provider:
- Sets a self-management goal collaboratively with patient.
- Performs comprehensive foot exam.
- The physician provider:
- Updates the diabetic flow sheet and encounter form.
- Reviews nursing documentation of the self-management goal and foot exam.
- After the visit, nursing staff:
- Sets aside diabetic charts in the clinic after billing forms are removed.
- Enters information from the encounter form and flow sheet into the clinical information system and registry.
- Calls patients to follow up on self-management goal.
The team acknowledged that the flow sheet was the biggest change to the practice; whereas, facilitating self-management goals was the biggest, yet most rewarding challenge.