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-Pediatrics team found that facilitating self-management goals was the biggest, yet most rewarding challenge.

Internal Medicine/Pediatric Clinic, Hoxworth Medical Practices

Your Name: ________________________________________

The best way to reach you during the day: _________________

Today's Date ____ / ____ / ____

The nurse who helped you today: _______________________

People who set their own goals with the support of their medical care team do better with long term diseases. All you need to get started is a little information, a clear plan, and the desire to make a difference in your health. Find an area you would like to change and pick a goal. Then mark on the ladder how confident you are to begin. This will let us know how best to help you reach your goal. Good Luck!!!!

How Confident AM I?

__Very Confident


__Sort of Confident

__Getting Ready

__Thinking about it

__Not Ready

Image of a ladder; top of the ladder aligns with very confident, and the bottom aligns with not ready.
After you pick a goal, check the place on the ladder that shows your confidence to get started.

1. Getting Active

  • I will start walking for 10 minutes a day, three times weekly.
  • I will find a friend to walk with and go three times weekly.
  • I will start by walking the length of my home five times daily.
  • I will __________________________________________.

2. My Diet

  • I will lose 2 pounds by reducing my portion sizes at dinner.
  • I will lose 2 pounds by eating one less bread serving daily.
  • I will replace fried and snack foods with fruit or vegetables daily.
  • I will _____________________________________________.

3. My Medicines

  • I will finish paperwork to get help buying my medicines.
  • I will write down my medicines, doses, and reason taken.
  • I will learn about how my medicines protect my health.
  • I will _____________________________________________.

4. Checking My Blood Sugar

  • I will check and write down my blood sugar twice daily for 2 weeks.
  • I will ask a friend to help me check my blood sugar.
  • I will find out more about why I need to check my sugars.
  • I will ____________________________________________.

5. My Daily Foot Checks

  • I will learn how to check my feet and start doing so daily.
  • I will not go barefoot at all.
  • I will learn what foot problems I should report to my doctor.
  • I will _____________________________________________.

6. Quit Smoking

  • I will set a quit date today as __________.
  • I will get support from my family and friends to quit.
  • I will learn new things to do instead of smoking.
  • I will enroll in a smoking cessation program.
  • I will ________________________________________.
Special Help Needed To Reach Your Goal
Date: ___ / ___ / ___
2 week follow up phone call with nurse
Follow up:
___ weeks ___ months

__ Appointment with diabetes educator
__ Appointment to quit smoking-pharmacotherapy
__ Comprehensive foot exam
__ Appointment with eye doctor
__ Appointment with my doctor

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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.