Toolkit for Implementing the Chronic Care Model in an Academic Environment

Collaborative Care Model Curriculum

The Internal Medicine Ambulatory Chronic Care curriculum targets block rotators—which are internal medicine residents assigned to a clinical rotation, such as primary care, for a designated length of time, such as a month—and faculty members and attending physicians who use the continuity clinic to see patients or supervise residents. The curriculum teaches the Chronic Care Model to residents.

EIP/ACCC Chronic Care Model Curriculum for IMC block rotator residents SUMMA IM—Initiated April 2006

Objective: To orient residents to a skill-based use of the advanced chronic care model in a continuity clinic setting.

Methods: Multiple tools and processes developed during our participation with the Academic Chronic Care Collaborative will be used to train residents as they see diabetic patients. Clinical outcome and performance data by practice and by physician will allow participating residents to change their own care practices.

Skills targeted for learning:

  1. A working knowledge of the chronic care model by literature review and faculty training.
  2. Ability to use tools developed to integrate chronic disease management with clinic care.
  3. Experience working with and leading a multidisciplinary care team in managing chronic disease.
  4. Ability to effectively use self management support to assess and develop patient readiness to perform self care.
  5. Experience in conducting group visits.
  6. Review of current advanced diabetic care with a clinical expert using algorithms.
  7. Use of patient feedback to improve chronic disease care.

Learning Activities in the Chronic Care Curriculum

Resident Activity Taught by
1.  Orientation to the chronic care model (CCM).
2.  Orientation to the IMC CCM tools and activities for diabetic care.
3.  Planned visit instruction (observe, run).
4.  Self-management goal support training.
5.  Participate in team care.
6.  Participate in a group visit for diabetes.
7.  Use patient feedback in chronic care.
Laptop PP with literature.
Laptop PP with literature.
NP and faculty.
Linda Sims, Clinical Psychologist.
Jim Salem, Endocrinology.
Faculty review.
Orientation assessed by post quiz.
Planned visit by self survey and Mini-CEX.
Self Management Support by observed feedback.
Team participation by self-survey completion and faculty observation.
Feedback by summary with narrative.
Resident Formative Assessment to portfolio.
Practice based learning report to portfolio.
80 percent required to complete.

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Collaborative Care Model Curriculum. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.