Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Planned Visits-Oregon Health & Science University

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. Oregon Health & Science University's approach follows.

Diabetes Planned Visits

Oregon Health & Science University

Prior to Planned Visits

Team Huddle. In advance of Oregon Health & Science University's regular Monday morning meeting, a medical assistant prints and distributes Patient Diabetes Summary Sheets to the team for each of the 8 to 16 patients scheduled for a planned visit.

At 8:30 a.m. the team "huddles" in the conference room to review and discuss the data on the summary sheets, with every team member responsible for reviewing the charts from their own role and perspective. Attending the interdisciplinary meeting with residents are general internist faculty, a nurse, a case manager, a social worker, and a medical assistant.

During the huddle:

  • Each resident reviews summary sheets of the patients they are scheduled to see during the day's planned visits, discussing the patient's current status on measures of interest, relevant health history, diabetes management plans, progress on self-management goals, and relevant psychosocial aspects of the patient's situation.
  • The medical assistant updates the team on each patient's status on process measures performed by medical assistants, such as foot exams, smoking status, immunizations, eye examinations.
  • The nurse and social worker provide information regarding contacts between visits and the status of each patient's current social, psychological, socioeconomic needs, and support relevant to management of chronic conditions.

Team decisions are then made regarding who, besides the residents and faculty physicians, will see each patient and what needs to be accomplished during the visit. For example, if a patient is having trouble getting medications, the social worker will see the patient first and make a plan for accessing subsidized or free medication programs.

During the Planned Visit

Considering the issues team members raise, residents conduct planned visits with patients scheduled for the morning and present their findings and decisions to the attending physician.

The faculty member then sees the patient with the resident to confirm findings and plan, to role model self-management action planning, or to help with additional decisionmaking. "Hallway" huddles also occur frequently between the registered nurse, social worker, resident, medical assistant, and faculty member to assure timely communication during the visit.

The resident and attending physician see patients from 8:45 to 11:45 a.m. The conference room's close proximity to the exam rooms contribute to a cohesive team approach to conducting the visits.

During the visit, residents support patients in meeting self-management goals, collaborating with them to:

  • Inform patients of their responsibilities, such as reminding them to check their blood sugars.
  • Provide patient education, (e.g., asking the registered nurse to instruct the patient how to use the glucometer).
  • Set specific, measurable, patient-centered action plans that support the development of confident, informed patients with skills to self-manage their diabetes.
Post-Visit Huddle

After the visits, the team gathers for a post-visit huddle to discuss what happened during the visit and to plan followup calls to check on patient progress to help build partnerships between the team and the patient.

In general, the team considers huddles before and after planned visits essential to the success of the team approach. Not only do the huddles build team rapport, they promote effective communication, empower residents and staff, and generate breakthrough ("a-ha") moments that often significantly influence the overall care plan for a specific patient.

Information and Knowledge Support

The team developed a "Smart Form template" for entering and updating the registry. Before implementing the electronic health record in October 2005, the registry was updated after each visit by hand, usually by the team registered nurse.

The online registry smart form requires data entry at the time of the visit, and is accomplished by the team member responsible for the specific process (e.g., foot exams and immunization dates by the medical assistant and medication updates by the registered nurse or physicians).

Currently, the registry runs parallel to the Epic electronic medical record, requiring some duplication of data entry. The registry (not Epic) information system supports automated production of diabetic care summary sheets at the point of care. These sheets serve as a current status report and trigger for care planning in the pre-clinic huddle.

The Diabetic Care Summary sheets are a critical part of the improvement success for this team. These summary sheets provide a snapshot of each patient's care status, serve as reminder of the treatment protocol, allow for a longitudinal view of the patient's response to care over time, and provide a focus for the team huddles and care planning for each patient.

In addition to providing best practice alerts based on patient data, the team is also developing a care management tracking database that enables the team to communicate effectively about contacts and care changes between visits.


Smart Form Template
Diabetic Care Summary

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