Implementation of a Chronic Illness Model for Diabetes Care in a Family Medicine Residency Program

As part of the California Academic Chronic Care Collaborative, the San Jose–O’Connor Family Medicine Residency Program, affiliated with Stanford University, formed a diabetes management program modeled on the Chronic Care Model (CCM). Six residents, two faculty and clinic staff sought to redesign the delivery of care for diabetic patients by incorporating specific elements of the CCM into residency training and practice. Their goal was a 25 percent or greater overall improvement in the patients with diabetes in their care. Prior to the collaborative, the residency program did not have a chronic illness curriculum for residents.

Residents participated in workshops and completed monthly diabetes performance reports on 13 metabolic and process measures, along with comparisons to previous month’s individual provider performance and the group's overall performance. They attended collaborative-wide learning sessions and team meetings and took part in quality improvement activities following the plan-do-study-act cycle. They created and maintained a diabetes registry and used diabetes flow sheets with imbedded evidence-based guidelines. Residents also received instruction on diabetes management and patient self-management.

Overall, the proportion of patients who achieved blood glucose, cholesterol and blood pressure goals simultaneously increased from 5.7 percent to 17.1 percent.

The project provides evidence that residency programs can successfully incorporate chronic care training for residents while improving patient care.