Toolkit for Implementing the Chronic Care Model in an Academic Environment
Diabetes Planned Visits-Summa Health System
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. Summa Health System—Family Practice staff's approach follows.
Diabetes Planned Visits
Summa Health System—Family Practice
Designing Diabetes Planned Visits
Summa's Family Medicine team consisted of all members of the family practice staff. The team decided at its kickoff meeting that all 396 diabetes patients in the family practice registry would be included in the pilot population (excluding those in nursing homes and those with dementia). The underlying rationale for this decision was the belief that if enduring change was going to occur, everyone must experience the change at the same time.
To accommodate the high volume of planned visits, the team divided the number of visits (400) by the number of nurse coleaders (5) and assigned each of the resulting 80 patients and 40 residents to one of the five care teams.
Essential components of the planned visit itself consist of two patient-centered objectives:
- Addressing the concerns of the patient.
- Partnering with the patient to create a self-management goal.
At each diabetes planned visit, residents use the Self-Management Goal Sheet to set specific, realistic goals and plans for achieving them with the patient.
During followup visits residents use the Diabetes Report Card to update patients on their progress. The report card pulls patient data (e.g., blood pressure, LDL, HbA1c) from the registry and presents them in an easily accessible format. It includes information about the meaning and importance of each quality measure, lists previous self-management goals set by the patient, and provides an area for new goals.
The family practice team established their registry by using Microsoft Access®. Doing so allowed them to create their own tools for facilitating the planned visit model.
Implementing Planned Visits
The team conducts 20 to 30 planned visits per week, with each visit lasting about 30 to 45 minutes. The visits are scheduled two weeks in advance by nurse coleaders, who also check lab results and make sure patients have a lab test prior to the visit if the data are not current.
During the planned visit, residents follow an algorithmic outline detailing specific steps of the process, including:
- Determining if the patient is ready for a planned visit or has other, more pressing needs.
- Using the pre-visit questionnaire to conduct a comprehensive review of systems and screen for depression.
- Reviewing previous self-management goals.
- Conducting the physical exam.
- Reviewing results in the Diabetes Report Card.
The outline of the planned visit process and the pre-visit questionnaire are available for downloading and adapting, while general information on planned visits and the Chronic Care Model is available at the Improving Chronic Illness Care Web site.
Key components of the Family Practice Planned Visit
Two Weeks Before the Planned Visit
- The registered nurse team leader reviews the patient chart, orders labs, and highlights other health aspects for the physician (e.g., immunizations, cancer screening, etc.).
- The registered nurse team leader calls the patient to remind him or her of the appointment and to get lab tests and faxes lab orders to the laboratory.
- The registered nurse team leader prints out a patient data sheet, which includes smoking status, body mass index, recent low-density lipoprotein levels, etc., for physician review.
- A faculty member provides suggestions (academic detailing and decision support) for the resident to consider as a way to help the patient achieve his or her goal.
During the Planned Visit
- When the patient arrives, the receptionist asks if he or she has had blood work done and brought medications. The patient completes the pre-visit questionnaire, if it is not already complete.
- After recording the patient's weight and height, the licensed practical nurse reviews the Diabetes Report Card with the patient and encourages him or her to complete the Self-Management Worksheet to create a meaningful self-management goal.
- Using the team's Diabetes Planned Visit Notebook the resident spends 15 to 20 minutes to refine the self-management goal, answer questions, perform needed physical examinations, and recommend changes in therapy as appropriate. A faculty adviser is available for consultation during the exam.
The physician schedules the next planned visit and gives the patient a prescription for lab any tests that are needed before the next visit.
After the Planned Visit
Physicians may schedule the patient for a nurse visit, if needed, to address education issues, blood pressure control, insulin initiation, etc. The physician may also consult the social worker if patients have transportation barriers or difficulty affording medications.
The faculty adviser reviews the patient chart and provides the resident with feedback on management and documentation.