4. Health Professions Education for Chronic Care

In implementing the Chronic Care Model into the internal and family medicine curriculums, the pilot sites discovered a number of challenges when training residents on conducting planned visits.

For example, the internal medicine team at Summa Health System learned that:

• The pilot site's clinic schedule worked against unscheduled teaching of the Chronic Care Model.
• Residents were relatively unprepared conceptually to use components of the model.
• Residents had difficulty helping patients choose a measurable behavior for self-management goals, despite aids such as the Smart Goal sheet form.

Based on these findings, the team developed an Internal Medicine Ambulatory Chronic Care Curriculum in the internal medicine continuity of care clinic. The 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.

Chronic care curriculum items are indexed to residents' learning portfolios and itemized by competency. 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).

As such, the curriculum seeks to instill:

1. A working knowledge of the Chronic Care Model through literature review and faculty training.
2. An ability to use tools developed to integrate chronic disease management with clinic care practices. Tools are integrated with the emergency health record in the ambulatory clinic.
3. Experience working with and leading a multidisciplinary care team. Residents are observed and receive feedback for improvement.
4. An understanding of using a planned visit for patients with diabetes. Residents are observed and receive feedback for improvement.
5. Experience in using self-management support to assess, motivate, and assist patient readiness for self care.
6. Practice in supervising group visits.
7. A review of current advanced diabetic care with a clinical expert.
8. Use of structured patient feedback to improve chronic disease care.

Summa's family practice team developed an approach for integrating residents into the process and teaching them about chronic care, process change and team building.   Every month the team convenes a half-hour chronic care meeting. All faculty, second- and third-year residents, nurses, available ancillary staff, and rotating medical students are required to attend. Each meeting's agenda consists of a diabetes team presenting:

• A report on process or outcome data.
• A report on a plan-do-study-act cycle to address problems with process or outcome.
• A brief educational presentation, usually done by the third-year residents on the team, relevant to diabetes care (e.g., glucose control, self-management goal setting, renal disease in diabetes mellitus, blood pressure control and medication titration, or starting insulin and titrating insulin.)

After the meeting the teams are encouraged to meet individually to discuss their next plan-do-study-act cycle.

The family practice team uses this format to document the completion by second- and third-year residents of the competencies required as part of their Chronic Care Portfolio. Although diabetes currently remains the team's main focus, their members hope to expand their topics to include other relevant chronic diseases.

To overcome similar challenges in implementing the Chronic Care Model in resident education, the Oregon Health & Science University developed a chronic illness management block rotation.

The chronic illness management block rotation exposes residents to chronic care concepts including:

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

Additionally, the rotation includes practice experience with the Chronic Care Model, a focus on diabetes care in the model, and experience with patients who have chronic pain.

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.

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