Chronic Care Portfolio

Toolkit for Implementing the Chronic Care Model in an Academic Environment

Summa Health System's family practice team requires second- and third-year residents to demonstrate competency in the Chronic Care Model as part of their Chronic Care Portfolio. Requirements for completing the portfolio are below.

Resident Chronic Care Portfolio

Diabetes mellitus, anticoagulation, well-child care, immunizations, cancer screening, etc.

• Query registry (2) one for self, one for team.
• Propose plan-do-study-act (2) one for self, one with team.
• Review appropriate evidence-based medicine guideline for plan-do-study-act cycle and report search results.
• Report on plan-do-study-act resolution (2).
• Morning report PowerPoint presentations (2).
• Case study of difficult patient and how the problem was addressed.
  • Include patient narrative, self-management goals, use of team, and use of community resources.
• Chronic care update: decision support.
  • Decision support topics.
    • Self-management goal, glucose control, blood pressure control, lipid control, oral medications, insulin, nephropathy, painful neuropathy, autonomic neuropathy/gastroparesis, foot care, eye care, sick day, peri-procedural management, depression, financial issues, hospital care of diabetes mellitus.
• Report on self-management goal process and success in chronic care huddle the day after a chronic care visit.

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