Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Planned Visits-University of Cincinnati Academic Health Center

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-pediatric team's approach follows.

Diabetes Planned Visits

University of Cincinnati Academic Health Center

Hoxworth Internal Medicine-Pediatric Team

The Hoxworth internal medicine-pediatric team developed a clinical diabetes visit process for individual patients as well as one for group visits.

The process for individual visits was applied to all the patients with diabetes in the population of focus, regardless of their chief complaint. The basic procedure used the encounter form, flow sheet, and Smart Goal sheet:

  • Before the visit, front office staff:
    • Identifies the diabetic patients' charts, which are tagged with an orange sticker with a "D" on it.
    • Prints an encounter form, highlighting missing info.
    • Puts flow sheet and self-management sheets on chart.
  • During the visit, the nurse, medical assistant, or provider:
    • Sets a self-management goal collaboratively with patient.
    • Performs comprehensive foot exam.
  • The physician provider:
    • Updates the diabetic flow sheet and encounter form.
    • Reviews nursing documentation of the self-management goal and foot exam.
  • After the visit, nursing staff:
    • Sets aside diabetic charts in the clinic after billing forms are removed.
    • Enters information from the encounter form and flow sheet into the clinical information system and registry.
    • Calls patients to follow up on self-management goal.

The team acknowledged that the flow sheet was the biggest change to the practice; whereas, facilitating self-management goals was the biggest, yet most rewarding challenge.


Electronic Encounter Form
Diabetic Flow Sheet
Smart Goal Sheet

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