Toolkit for Implementing the Chronic Care Model in an Academic Environment

Chronic Care Curriculum Podcast Modules

Summa Health System's internal medicine team used self-guided learning podcasts to provide residents a brief and easily accessible way to review specific topics. Residents receive immediate feedback using a Web-based post-test that assesses their learning. This use of Web-based learning has allowed the entire care team to gain an understanding of the clinical approach to take for patients who have not achieved clinical goals for their disease state. This improved knowledge has played a role in better patient outcomes.

Summa IM Ambulatory Chronic Care Curriculum


Module 1: Orientation to the Chronic Care Model

Method: Faculty laptop instruction module with interview and post test

Learning Objectives:

  1. Understand the current state of chronic care and the need for change.
  2. Become familiar with the six elements of the chronic care model, the literature support for their use, and their relationship to a health care system.

Measures: Post test; discussion with faculty.

Module 2: Orientation to Chronic care Model Tools used in the Pilot Clinic

Method: Faculty laptop instruction with interview, demonstration of tools, post test

Learning Objectives:

  1. Become familiar with the processes and tools that will be used to implement the chronic care model in care of IMC patients with diabetes.
  2. Understand the activities residents will employ during the ambulatory care month to begin to use the chronic care model in the care of patients.

Measures: Post test; discussion with faculty.

Module 3: Use of Self Management Support in Chronic Disease

Methods: Faculty guided discussion about SMG theory and strategies for use.
Resident will employ SMG support in the care of patients and rate their own level of use with a post-survey.
Resident observed using SMG support with a patient and use of feedback.

Learning Objectives:

  1. Resident will gain a detailed understanding of modern self management support strategies and begin using them in the care of patients with chronic disease.

Measures: Post test; observation and feedback using strategies with patients.

Module 4: Planned Diabetic Visits

Methods: Nurse practitioner leads a planned diabetic visit with resident participation. Resident-run planned visit allows feedback from nurse practitioner in observed setting.

Learning Objectives:

  1. Resident will become oriented to the concept of a planned visit.
  2. Resident is introduced to team care.
  3. Resident will receive an introduction to the use of decision support, registry information systems data use and self management support collaboration in chronic care.
  4. Resident will receive orientation to the use of algorithms for intensified care in chronic disease.

Measures: Nurse practitioner will observe resident run planned visit and will give feedback on use of checklist, performance in self management goal collaboration and use of intensification algorithms.

Module 5: Attend an Inter-Professional Team Meeting for Diabetes

Methods: The resident will attend one or more inter-professional team sessions where diabetic progress is reviewed and changes implemented. An endocrinologist, nurse practitioner, pharmacist, nutritionist, social worker and clinical psychologist will be in attendance. The resident presents a case from the pilot population not at clinical goal, reviews barriers to care, self management goal completion and efforts thus far at intensification. The team interacts with the resident to create and implement an effective response.

Learning Objectives:

  1. Become an active participant in inter-professional team care.
  2. Understand methods to overcome barriers to good care, including a failure to activate patients for self care, clinical inertia and lack of resources.
  3. Understand and use algorithms to intensify care for patients not at clinical goal.

Measures: Faculty gives written feedback on resident interaction and insight.

Module 6: Attend and Assist During a Scheduled Diabetic Group Visit

Methods: Resident is scheduled to participate in conducting a group visit for 6-10 diabetic patients and their caregivers. Orientation is given by the nurse practitioner prior to the visit.

Learning Objectives:

  1. Understand the role and practical use of disease specific group visits in the care of chronic disease.
  2. Gain experience in conducting a group visit.
  3. Understand methods to properly bill third party payors for group visits.

Measures: Observation and feedback on participation and understanding of this activity.

Module 7: Use of the Patient Feedback Survey for Chronic Disease

Methods: Resident will receive the results of a performance survey completed by patients seen under their care which related to all elements of the chronic care model (P-ACIC)

Learning Objectives:

  1. Resident will gain valuable insight to the patient's perception of their own care and effective use of the chronic care model.

Measures: Resident will perform a self assessment based on their survey results. They will write a narrative including changes made to their own practice based on the survey results. This will be reviewed with supervising faculty and included in the resident portfolio for the experience as a professionalism and practice based performance and improvement competency record.

Resident Formative Assessment for the Chronic Care Curriculum
Based on direct observation by faculty and self assessment by the resident: Portfolio

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Chronic Care Curriculum Podcast Modules. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.