Journal of General Internal Medicine

, Volume 25, Supplement 4, pp 615–619 | Cite as

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

Original Research



While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.


Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.


University-affiliated, community-based family medicine residency program.


Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.


We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.


Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.


chronic care model learning collaborative diabetes residency education 



This program was funded by Improving Chronic Illness Care and the California Health Care Foundation, in collaboration with the Association of American Medical Colleges. The authors would like to acknowledge the hard work of all of the participants of the OFHC Diabetes Management Team, with special thanks to the following individuals: David McKay, MD, MPH; Robert Norman, MD; Nancy Morioka-Douglas, MD, MPH; Leticia Martinez, RN; Jena Eidschun; David Hiroshima, MD; Tam Nguyen, MD; Rowan Paul, MD; Christie Shen, MD; and Katherine Vega, MD. The authors also thank the faculty of the CA-ACCC, Ed Wagner, MD, MPH; David Stevens, MD; Judith Bowen, MD; and Connie Sixta, RN, PhD, MBA, for their guidance and support, and the representatives of the other participating institutions for their sharing and dissemination of ideas and best practices.

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  1. 1.San Jose-O’Connor Family Medicine Residency ProgramSan JoseUSA

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