The Chronic Care Model and Exercise Discussions
during Primary Care Diabetes Encounters
Neela K. Patel, MD, MPH, and Michael L. Parchman, MD, MPH
Background: Discussing self-care activities like exercise is challenging with the many competing de-
mands during primary care encounters. Our objective was to study the relationship between the Chronic
Care Model (CCM) score in the clinic and time spent by the physicians discussing exercise during en-
counters with diabetic patients.
Methods: Consecutive patients with diabetes across 20 primary care clinics in South Texas were in-
cluded. Time spent discussing exercise was determined using the Davis Observation Code on audio re-
cordings of the visits. Clinicians completed the Assessment of Chronic Illness Care survey, a validated
measure of the extent to which care delivered is consistent with the CCM. Data were analyzed using hi-
erarchical linear models.
Results: A total of 162 transcribed recordings were analyzed. Age, the number of problems ad-
dressed, stage of change (SOC), and overall length of the visit were associated with time spent discuss-
ing exercise. There was a significant relationship between clinic CCM score and time spent by physicians
advising about exercise, independent of SOC for exercise (P < .01). Also, a discussion about exercise
was more likely to occur with patients who were in the contemplation SOC for exercise.
Conclusions: Discussions of exercise may be 18 to 33 seconds longer in clinics with full implementa-
tion of the CCM compared with those with basic implementation. Facilitating more complete CCM imple-
mentation in clinics with a basic level of CCM that serve a population of patients who are sedentary may
realize the most benefit. (J Am Board Fam Med 2011;24:26–32.)
Keywords: Chronic Care Model, Diabetes, Exercise, Patient Education
Primary care physicians can play an important role
in supporting self-care activities, such as exercise
among patients with a chronic illness.1Despite the
evidence of effectiveness of preventive services and
supporting self-management behaviors,2,3primary
care encounters are bounded by time constraints
within which multiple diagnoses, problems, and
patient concerns compete with each other for a
place on the agenda.4These multiple competing
demands often result in health behavior counseling
taking a back seat to issues and concerns considered
more pressing or important.2
The Chronic Care Model (CCM) suggests that
interactions between informed activated patients
and prepared, proactive care teams can produce
better care and improved outcomes.1,5The CCM
was developed by identifying 6 evidence-based el-
ements associated with improved chronic illness
outcomes. It is based on the concept that when
proactive patient care teams provide care to in-
formed, activated patients, clinical quality and out-
comes will improve. For example, for patients to
engage in proactive care (delivery system design),
practices need to be able to view all the patients in
This article was externally peer reviewed.
Submitted 15 June 2010; revised 20 September 2010; ac-
cepted 4 October 2010.
From the Department of Family and Community Medi-
cine, University of Texas Health Science Center at San
Antonio (NKP & MLP); and Verdict Health Services Re-
search Program, South Texas Veterans Health Care System
(MLP), San Antonio.
Funding: The research reported was supported by the
Agency for Healthcare Research and Quality (AHRQ K08
HS013008-03) and the Bureau of Health Professions; Health
Resources and Services Administration Department of Health
and Human Services grant D01 HP08795; The John A Hart-
ford Foundation Center for Excellence in Geriatrics Educa-
tion; and by the Department of Veterans Affairs.
Conflict of interest: none declared.
Disclaimer: The views expressed in this article are those of
the authors and do not necessarily represent the views of the
Department of Veterans Affairs.
Corresponding author: Neela Patel, MD, MPH, The Uni-
versity of Texas Health Science Center at San Antonio,
MC-7795, 7703 Floyd Curl Drive, San Antonio, TX 78229-
3900 (E-mail: Pateln4@uthscsa.edu).
January–February 2011Vol. 24 No. 1http://www.jabfm.org
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