Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Planned Visits-Vanderbilt University Medical 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 Vanderbilt University Medical Center's approach follows.

Diabetes Planned Visits

Vanderbilt University Medical Center

Developing the Chronic Disease Management group, along with involving residents in planning and conducting plan-do-study-act cycles, were major elements underlying the Vanderbilt University Medical Center's approach to planned diabetes visits.

As the process outline below indicates, the Diabetes Dashboard provided physicians with updated "just-in-time" patient data through laptop computers in the exam room.

The Planned Diabetes Visit includes the following process:

  • The Patient Care Technician (PCT) asks the patient at check-in if he or she has diabetes.
  • If the patient is diabetic, the PCT alerts the nurse, who prepares a form that provides HbA1c levels, blood pressure, cholesterol levels, and reminders about foot and eye exams. (Select for Vanderbilt University Medical Center's ABC Form).
  • The nurse performs a mandatory diabetes foot exam and reviews medicines with the patient, entering the data into the electronic medical record.
  • The physician reviews the patient's updated "just-in-time" information on the Diabetes Dashboard and collaborates with the patient on setting or managing self-improvement goals.

When the visit concludes, a member of the staff makes three copies of the form:

  1. One copy is given to the patient as a reminder of his or her progress and what was discussed during the clinic visit. The copy also serves as a reminder to the patient of his or her health goals for the next week.
  2. One copy is sent to the Chronic Disease Management Group that will contact the patient in a week to check the patient's progress with the goal.
  3. The third copy is scanned into the patient's electronic medical record as a record of the visit's discussions and is filed.


ABC Form

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