Toolkit for Implementing the Chronic Care Model in an Academic Environment

The Oregon Health & Science University developed a chronic illness management block rotation as part of its Chronic Care Model in resident education. The block rotation exposes residents to chronic care concepts including epidemiology, gaps between best practices and usual care, a model for improvement and plan-do-study-act cycles, and use of a registry.

Chronic Illness Management Block Rotation

In 2003, Oregon Health & Science University's internal medicine residency program had an opportunity to focus a portion of the outpatient curriculum on new models for managing chronic conditions.

Building on the internal medicine practice's early experience with the Chronic Care Model and the Oregon Diabetes Collaborative (1999-2000), a 4-week block rotation was created called the Chronic Illness Management (CIM) Block. All 90 residents in Oregon Health & Science University's program are assigned to this rotation at least once during their 3 years of training. Primary care track residents are assigned as first-year residents and again as second-year residents.

This rotation includes practice experience with the Chronic Care Model, a focus on diabetes care in the model, and experience with populations of patients with chronic pain. More recently, experience with behavioral medicine and women's health has been added, and registry support for these practices is under development.

The CIM-diabetes practice with residents occurs every Monday and Thursday morning. The CIM rotation exposes residents to chronic care concepts including:

• Epidemiology of chronic illnesses.
• The gap between best practices and usual care.
• A model for improvement and plan-do-study-act cycles.
• Use of a registry in planning and monitoring improvement, planned visits, ambulatory practice-based teamwork, and self-management action planning with patients.

Patients are seen in CIM-diabetes practice after a referral from their primary care physicians, either residents or faculty in the internal medicine practice. Based on their stage of diabetes, their degree of optimization on process and outcome metrics, and their primary care physician's desire, patients are seen:

• Two to three times in the first three months (for intensification of therapy).
• Every three months (for lifestyle management).
• Annually when their diabetes is under control.

Oregon Health & Science University's Monday and Thursday morning meetings follow a regular agenda that includes:

• Medicine resident teaching conference.
• A plan-do-study-act cycle discussion.
• A team huddle to plan visits.
• Planned diabetes visits.
• A team post-clinical huddle to plan followup.

Resident Teaching Conference

The CIM Monday session begins at 7:30 a.m. with a weekly 30-minute resident teaching conference that provides decision-support topics aimed at overcoming clinical inertia for patients with diabetes.

The topic presented during the Agency for Healthcare Research and Quality site visit was "Titrating Insulin to Glycemic Target," in which the group discussed the titration protocol for patient self-management of insulin. The team shared many patient successes with the protocol in which schedules are based on blood sugar level and patients receive followup phone calls, appointments, or both, depending on their level of confidence with self-management of basal insulin dosing.

Plan-Do-Study-Act Cycle Discussion

At 8 a.m. the entire diabetes team convenes to participate in a plan-do-study-act cycle. During the site visit, the team reviewed a plan-do-study-act cycle focused on patients with HbA1c values between 7 and 9 who keep regular appointments for any reason in the internal medicine practice.

As a precursor for scheduling a group visit, the team identified patients on insulin with a need for treatment intensification and patients who should be started on insulin.

The group discussed the need to engage the faculty on this project and decided they would review the data with faculty in a half-hour focus group. It was also suggested that the identified patients be brought in for a CIM visit to potentially initiate insulin treatment and then return them to the faculty practice.

Because of the time-intensive nature of this clinical work, the group predicted that faculty would appreciate the effort and teamwork in supporting these patients. From earlier plan-do-study-act cycles and based on outcome measures, at least one faculty member has referred all his patients with diabetes to this care model.

The plan-do-study-act cycle concluded with all tasks assigned and patient-specific spreadsheets from the registry E-mailed to group members for followup and planning of the group visit.

Team Huddle

In advance of the Monday morning meetings, 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 these sheets. Every team member is responsible for reviewing the chart from his or her own role and perspective. Attending the interdisciplinary meeting with residents are physicians, a nurse, a case manager, a social worker, and a medical assistant.

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