Toolkit for Implementing the Chronic Care Model in an Academic Environment

To reinforce the chronic care curriculum, residents receive a Resident Curriculum Pocket Card. The curriculum is longitudinal, allowing advancement by acquiring skills in the use of the Chronic Care Model through novice, competent and expert levels. Third-year residents (experts) assist in training first-year learners (novices).

Resident Curriculum Pocket Card

Resident Completion of Learner 1
(Novice) Level Chronic Disease

______      Complete Learner Module 1 Pre- and Post-test (Post-test at 80 percent or above).

______      Observe a Diabetic Planned Visit.

______      Present a diabetic case for interdisciplinary discussion at the monthly team meeting.

______      Review diabetic podcasts at imsumma.org and complete post tests at 80 percent or above.

______      Review algorithms for diabetic care for improved quality.

______      Attend self-management goal learning session and coach one patient in goals.

______      Attend one Change Team meeting.

______      Attend one Group patient session.

Resident Completion of Learner 2
(Competent) Level Chronic Disease

______      Complete Learner Module 2 Pre- and Post-test (Post-test at 80 percent or above).

______      Observed/given feedback performing a Diabetic Planned Visit.

______      Present a diabetic case for interdisciplinary discussion at the monthly team meeting: exhibit team care skills.

______      Review Registry learning materials; use EHR to evaluate personal practice chronic disease care.

______      Use algorithms to intensify care in three patients with chronic disease.

______      Observed/given feedback using self management goal setting with a patient.

______      Attend one Change Team meeting; understands use of PDSAs (small tests of change) in practice quality improvement.

______      Address at least one issue of health literacy or clinical inertia at a group patient session.

Resident Completion of Learner 3
(Expert) Level Chronic Disease

______      Complete Learner Module 3 Pre- and Post-test (Post-test at 80 percent or above).

______      Demonstrates elements of a Diabetic Planned Visit for Novice (Level 1) learners.

______      Able to lead an interdisciplinary team discussion of a diabetic high risk patient.

______      Has participated in at least one PDSA test of change to improve quality or safety of chronic disease care in the continuity clinic.

______      Has participated in a Firm discussion of quality using a registry report; has initiated changes to care to improve outcomes.

______      Has addressed at least one issue of office efficiency or workflow related to the care of patients with chronic disease.

______      Regularly uses self management support to collaborate with patients and can explain its use to Novice (Level 1) learners.

______      Participate in planning at least one Group patient session.

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