Toolkit for Implementing the Chronic Care Model in an Academic Environment

Residents, Staff, and Patients Working as a Team

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:


Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Residents, Staff, and Patients Working as a Team. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.