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Integrating the chronic-care model and the ACGME competencies: using shared medical appointments to focus on systems-based practice
  1. S R Kirsh1,
  2. D C Aron2
  1. 1
    Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
  2. 2
    Case Western Reserve University School of Medicine, Cleveland, OH, USA
  1. S R Kirsh, Medical Service (111W), Louis Stokes Cleveland VA Medical Center, 10701 East Blvd., Cleveland, OH 44106, USA; susan.kirsh{at}

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There is an increasing need for physician trainees to learn management of chronic illness. Training in chronic illness management is complicated by the acute care orientation of most healthcare systems. Coming on top of the broadening range of competencies that reflect the changing needs of healthcare delivery is the shift in evaluation of physician trainees in several countries to competency-based methods.12 The Accreditation Council for Graduate Medical Education (ACGME) has defined six core competencies: systems-based practice, practice-based learning and improvement, patient care, medical knowledge, interpersonal and communication skills and professionalism.3 Explicitly included now are two competencies essential for effective patient care and quality improvement—Systems Based Practice (SBP) and Practice Based Learning and Improvement (PBLI). Although all six competencies apply to management of chronic illness, these two have been the most difficult for residency programmes to address in any comprehensive manner.46 Training venues that mesh a systems approach to high-quality outpatient care for chronic illness with effective teaching are needed.710 Among the models proposed for healthcare system redesign is the chronic-care model (CCM) of Wagner et al. We suggest that this model with its six major elements (delivery system design, information systems, healthcare system, self-management, decision support, and community, italicised below for clarity) provides a conceptual framework around which education about chronic disease management can be organised.1112 We describe how we use a CCM-inspired outpatient clinic redesign, the diabetes shared medical appointment (SMA), to address the six core competencies. We illustrate how management in this setting of a paradigmatic chronic illness involves all six competencies and emphasise its utility, especially in SBP. We will discuss the six components of the CCM by heading and their application in our setting.


Delivery system design

SMAs, also called “cluster visits,” “group visits” or “chronic healthcare …

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  • Competing interests: None.

  • The views expressed are solely those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs.