Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Planned Visits-University of Cincinnati Academic Health Cente

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 approach follows.

Diabetes Planned Visits

University of Cincinnati Academic Health Center

Hoxworth Internal Medicine
  1. The Hoxworth internal medicine team implemented two major changes that helped with planned visits. The team improved its clinical information system and held regular team meetings to improve its delivery system design and accommodate its planned visit approach.

Clinical information system. The team, composed of seven residents, the program's medical director, and one nurse practitioner, transformed its paper-chart system to an electronic health record that accurately captures and quickly recalls clinical information for 201 diabetic patients.

The team's first chart extraction, done by an independent nurse hired from outside the team, was unsuccessful because the nurse was not familiar with what information was relevant. Practitioners on the team performed the second chart extraction themselves, with help from clinical staff, and were able to capture more relevant data.

The team used these efforts to develop an electronic encounter sheet to identify diabetic patients involved in the planned visit pilot. The team could access general data organized demographically, by planned visit, and by most current test results. Physicians were also able to access data arranged around their patient base and by specific report (e.g., by HbA1c results).

Team Meetings. The team also initiated weekly team meetings that residents attended as schedules permitted. These meetings focused on improving a particular aspect of patient care and were held from 1-1:45 p.m. (specifically not during lunch). The meeting format emphasized ways the group could improve care (e.g., "What can we do to change the HbA1cs?") rather than focusing on what was wrong. One of the most important changes the team generated from this approach was the Ambulatory Insulin Titration Form.

  1. The two major challenges the team encountered to improving its clinical information system and team building included the slowness of the clinical information system and registry and residents' busy schedules.

However, along with refining the clinical information system, regular team meetings strengthened the team approach to the diabetes planned visits, which followed the basic process outlined below:

  • Before the planned visit:
    • The office reviews the registry to identify diabetic patients for planned visits by generating a list of patients with an HbA1c of greater than 8.0, and then contacting the patients to schedule a planned visit.
  • During the visit:
    • The front office prints registry sheet when the patient arrives for the visit and gives to the nurse.
    • The nurse reviews registry sheet with the patient and highlights the visit.
    • The patient fills out three questions on the self-management sheet and prepares for a foot exam. The self-management sheet and progress notes are available electronically.
    • The physician discusses the situation with the patient and asks general questions about how patient's self-management is going.
    • The physician conducts the specific examination.
    • To close the loop, the physician asks the patient to review what was decided during the visit.
  • After the visit:
    • The front desk schedules a followup visit with the patient and tells the patient that the office will be calling within a week to follow up on self-management care (e.g., blood sugar level).
    • The nurse contacts the patient within a week to review care with the patient and completes the progress note that is available electronically.
    • The nurse tells the patient that he or she will be contacted again within a week to review blood sugar levels.


Electronic Encounter sheet
Ambulatory Insulin Titration Form

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Diabetes Planned Visits-University of Cincinnati Academic Health Cente. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.