Organization of Diabetes Care

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Maureen Clement MD, CCFP Betty Harvey RNEC, BScN, MScN Doreen M. Rabi MD, MSc, FRCPC Robert S. Roscoe BScPharm, ACPR, CDE Diana Sherifali RN, PhD, CDE

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes.
  • Diabetes care should be delivered using as many elements as possible of the chronic care model.
  • The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including self-management support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination.
  • Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback.

Helpful Hints Box: Organization of Care

Recognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.

Register: Develop a registry for all of your patients with diabetes.

Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists.

Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes.

Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.


In Canada, there is a care gap between the clinical goals outlined in evidence-based guidelines for diabetes management and real-life clinical practice (1,2). Since almost 80% of the care of people with diabetes takes place in the primary care setting, there has been a shift toward delivering diabetes care in the primary care setting using the chronic care model (CCM) (3–5). The CCM is an organizational approach as well as a quality improvement (QI) strategy in caring for people with chronic diseases, the elements of which are evidence based. These elements facilitate planning and coordination among providers while helping patients play an informed role in managing their own care (6). Previous recommendations in this chapter, in 2008, focused on the daily commitment of the individual with diabetes to self-management, with the support of the interprofessional diabetes healthcare team. Although these are still critical elements of diabetes care, increasing evidence suggests that the CCM, which includes elements beyond the patient and healthcare provider, provides a framework for the optimal care of persons with diabetes (6–8). This chapter has been revised to reflect the importance of the CCM design, delivery and organization of diabetes care. Despite the use of new terminology ( Table 1 ), many of the previous recommendations have remained the same but have been reorganized to fall under specific components of the CCM and broadened to include elements such as the health system and the community (9). This is intended to assist the readers in increasing their understanding and use of the CCM framework in their daily practice.

The CCM and Organization of Diabetes Care

In many ways, diabetes care has been the prototype for the CCM ( Figure 1). Developed in the late 1990s, this model aims to transform the care of patients with chronic illnesses from acute and reactive to proactive, planned and population based. This model has been adopted by many countries as well as several provinces in Canada (13). Early studies showed that the following interventions improved care in the chronically ill: educating and supporting the patient, team-based care, increasing the healthcare provider’s skills and use of registry-based information systems (7,8,10). The current CCM has expanded on this evidence to include the following 6 elements that work together to strengthen the provider-patient relationship and improve health outcomes: 1) delivery systems design, 2) self-management support, 3) decision support, 4) clinical information systems, 5) the community, and 6) health systems. A recent systematic review found that primary care practices were able to successfully implement the CCM (6). Furthermore, incorporating most or all of the CCM elements has been associated with improved quality of care and disease outcomes in patients with various chronic illnesses, including diabetes (6,8,10,14–16). A recent systematic review and meta-analysis of QI strategies on the management of diabetes concluded that interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving care. Although some of the improvements were modest, it may be that, when the QI components are used together, there is a synergistic effect as noted in the above studies (12).

Table 1
Definition of terms (9–12)
A1C, glycated hemoglobin; SMBG, self-monitoring of blood glucose.
Chronic care model (CCM) The CCM is an organizational approach to caring for people with chronic diseases as well as a quality improvement strategy, the elements of which are evidence based. These elements facilitate planning and coordination among providers while helping patients play an informed role in managing their own care. This model has evolved from the original Wagner CCM (1999) to the expanded care model (9).
Elements of CCM
  1. Delivery systems designs
  2. Self-management support
  3. Decision support
  4. Clinical information
  5. The community
  6. Health systems
Primary care First contact and ongoing healthcare: family physicians, general practitioners and nurse practitioners
Shared care Joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral notices. Can also refer to the sharing of responsibility for care between the patient and provider or team
Quality Improvement Strategies
Audit and feedback Summary of provider or group performance on clinical or process indicators delivered to clinicians to increase awareness of performance
Clinical information systems The part of an information system that helps organize patient and population data to facilitate efficient and effective care. May provide timely reminders for providers and patients, identify relevant subpopulations for proactive care, facilitate individual patient care planning, and share information with patients and providers to coordinate care or monitor performance of practice team and care system.
Clinician reminders Paper-based or electronic system to prompt healthcare professionals to recall patient-specific information (e.g. A1C) or do a specific task (e.g. foot exam)
Collaboration A collaborative intervention is a method used to help healthcare organizations apply continuous quality improvement techniques and affect organizational change.
Continuous quality improvement Techniques for examining and measuring clinical processes, designing interventions, testing their impacts and then assessing the need for further improvement
Decision support Integration of evidence-based guidelines into the flow of clinical practice
Disease (case) management A structured, multifaceted intervention that supports the practitioner/patient relationship and plan of care; emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies May include education, coaching, treatment adjustment, monitoring and care coordination, often by a nurse, pharmacist or dietitian
Facilitated relay of information to clinician Clinical information collected from patients and sent to clinicians, other than the existing medical record (e.g. pharmacist sending SMBG results)
Patient registry A list of patients sharing a common characteristic, such as a diabetes registry May be paper based but increasingly is electronic, ranging from a simple spreadsheet to one embedded in an electronic health record
Patient reminders Any effort to remind patients about upcoming appointments or aspects of self-care (e.g. glucose monitoring)
Self-management education (SME) A systematic intervention that involves active patient participation in self-monitoring (physiological processes) and/or decision making (managing) (see Self-Management Education chapter, p. S26)
Self-management support In addition to SME strategies that enhance patients’ ability to manage their condition, including internal and community resources, such as disease management with patient reminders, monitoring and linkage to self-management support/interest groups
Team changes Changes to the structure of a primary healthcare team, such as:
  • Adding a team member or shared care, such as a physician, nurse specialist or pharmacist
  • Using an interdisciplinary team in primary routine management
  • Expansion of professional role (e.g. nurse or pharmacist has a more active role in monitoring or adjusting medications)
Lay leader Trained and accredited non-healthcare professional delivering a program that adopts a philosophy of self-management rather than the medical model
Telehealth Delivery of health-related services and information via telecommunications technology

CCM in Diabetes

Initial analyses of CCM interventions for improving diabetes care suggested that a multifaceted intervention was the key to QI (8,15,17). Organizations that provided diabetes care in accordance with the CCM provided better quality care than did organizations that were less likely to use elements of this model (18). Furthermore, the degree to which care delivered in a primary care setting conforms to the CCM has been shown to be an important predictor of the 10-year risk of coronary heart disease (CHD) in patients with type 2 diabetes (19). Initially, it appeared as if only process outcomes, such as behaviours of patients and caregivers, are improved with the CCM; however, with longer-term use of the model in clinical practice, improvements in clinical outcomes also are noted, such as reductions in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) levels (20). A large, 2-arm, cluster-randomized, QI trial, using all 6 dimensions of the CCM, found significant improvements in A1C and LDL-C and an increase in the use of statins and antiplatelet therapy among patients with diabetes (5). A recent meta-analysis of randomized controlled trials (RCTs) assessing the effectiveness of disease management programs for improving glycemic control found significant reductions in A1C with programs that included the fundamental elements of the CCM (21). Other trials found that use of the CCM improved cardiovascular (CV) risk factors in patients with diabetes (19,22). One large-scale analysis of a nationwide disease management program using the CCM and based in primary care reduced overall mortality as well as drug and hospital costs (23). The Assessment of Chronic Illness Care (ACIC) is a practical assessment as well as a research tool. It can help teams strategically involve themselves in a structured way to assess and identify gaps to develop into a more robust CCM (11).

Figure 1
The Expanded Chronic Care Model: Integrating Population Health Promotion.

Used with permission from Barr VJ, Robinson S, Marin-Link B, et al. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Hosp Q. 2003;7:73–80.

Elements of the CCM that Improve Care

Delivery systems design

The team
Current evidence continues to support the importance of a multi- and interprofessional team with specific training in diabetes within the primary care setting (10,12,21). The team should work collaboratively with the primary care provider who, in turn, should be supported by a diabetes specialist. Specialist support may be direct or indirect through shared care, an interdisciplinary team member or educational support (5,12). In adults with type 2 diabetes, this care model has been associated with improvements in A1C, blood pressure (BP), lipids and care processes compared to care that is delivered by a specialist or primary care physician alone (5,24–27). A reduction in preventable, diabetes-related emergency room visits also has been noted when the team includes a specifically trained nurse who follows detailed treatment algorithms for diabetes care (25). In Canada, observational data from primary care networks, whose approach is to improve access and coordinate care, suggest that patients who are part of these interdisciplinary teams have better outcomes and fewer hospital visits than patients who are not (28).

Team membership may be extensive and should include various disciplines. Those disciplines associated with improved diabetes outcomes include nurses, nurse practitioners, dietitians, pharmacists and providers of psychological support.

Nurses have always been, and continue to be, core members of the team. A systematic review (26)and recent meta-analysis (29)found that case management led by specialist nurses or dietitians improved both glycemic control and CV risk factors. Another study found improved BP outcomes with nurse-led interventions vs. usual care, particularly when nurses followed algorithms and were able to prescribe (30). In addition, a large RCT found that nurse-led, guideline-based, collaborative care management was associated with improvements in A1C, lipids, BP and depression in patients with depression and type 2 diabetes and/or CHD (31). Practices with nurse practitioners also were found to have better diabetes process outcomes than those with physicians alone or those employing only physician assistants (32). Small-group or individualized nutrition counselling by a registered dietitian with expertise in diabetes management is another important element of team-based care. A variety of individual and community healthcare support systems, particularly psychological support, can also improve glycemic control (33).

Recent meta-analyses involving people with both type 1 and type 2 diabetes showed a significant 0.76% drop in A1C (34)as well as improved adherence and quality of life (QOL) and reductions in adverse drug reactions and LDL-C with collaborative pharmacist intervention (35). A Canadian randomized trial that added a pharmacist to primary care teams showed a significant reduction in BP for people with type 2 diabetes (36). Therefore, pharmacists can play a key role in diabetes management, beyond that of dispensing medications.

Roles within the team and disease management
Flexibility in the operation of the team is important. Team changes, such as adding a team member, active participation of professionals from more than one discipline and role expansion, have been associated with improved clinical outcomes (10,12,21). The greatest body of evidence for improved clinical outcomes in diabetes is with promotion of self-management, team changes and case or disease management programs (5,10,12,21,27,37,38). In a systematic review and meta-analysis of QI strategies, the following QI strategy improved clinical outcomes, such as A1C, BP and cholesterol, as well as process outcomes, medication use and screening for complications: promotion of self-management, team changes, case management, patient education, facilitated relay, electronic patient registries, patient reminders, audits and feedback, and clinician reminders. The effectiveness of different QI strategies may vary based on the baseline A1C, with QI targeting professionals only beneficial when the baseline A1C control is poor. In practice, many of these QI strategies occur in concert with one another through the use of interprofessional teams.

Another recent meta-analysis by Pimouguet et al. (21)defines disease management as the “ongoing and proactive follow-up of patients that includes at least 2 of the following 5 components: patient education, coaching, treatment adjustment (where the manager is able to start or modify treatment with or without prior approval from the primary care physician), monitoring, care coordination (where the manager reminds the patient about upcoming appointments or important aspects of self-care and informs the physician about complications, treatment adjustments, or therapeutic recommendations).” The meta-analysis found that a high frequency of patient contact and the ability of the disease manager to start or modify treatment with or without prior approval from the primary care physician had the greatest impact on A1C lowering. Disease management programs also were more effective for patients with poor glycemic control (A1C ≥8%) at baseline (21). Other disease management strategies that have been associated with positive outcomes are the delegation of prescription authority and the monitoring of complications using decision support tools (26,27,30).

The primary care provider, who is usually a family physician, has a unique role in the team, particularly with regard to providing continuity of care. He or she is often the principal medical contact for the person with diabetes and has a comprehensive understanding of all health issues and social supports (39). In the past, there was some debate over whether specialist care or primary care yields better diabetes outcomes (40–43). Although physicians practising in hospital-based diabetes centres may be more likely to adhere to guidelines (44), general practice-based care is associated with higher patient follow-up (45). Certainly, there are patients with diabetes who may require ongoing, specialized care, such as children and pregnant women. There is also evidence that specialized care may be more beneficial in people with type 1 diabetes (46,47). In the CCM, collaborative, shared care is the ideal. However, the results of one Cochrane review did not support shared care (48). It should be noted, however, that several of the studies included in this analysis did not use all the elements of the CCM. Other, more recent studies have supported the shared care model (49)and have shown that specialist input into specialized diabetes teams at the interface of primary and secondary care improves care (5,50).

Self-management support

Self-management support, including self-management education, is the cornerstone of diabetes care in the CCM. Self-management education goes well beyond didactic disease-specific information. It is a systematic intervention that involves active patient participation in self-monitoring (physiological processes) and/or decision making (managing). Self-management enables the person with diabetes to take an active role in managing his or her own care through problem solving and goal setting, which can be facilitated through the use of motivational interviewing techniques. Self-management support, often through disease or case management, with strategies such as patient reminders, helps the individual in self-management. Evidence for diabetes self-management support and education is robust (12)and is covered in more detail in the next chapter (see Self-Management Education chapter, p. S26).

Decision support

Providing healthcare practitioners with best practice information at the point of care to help support decision making has been shown to improve outcomes. In a systematic review, evidence-based guideline interventions, particularly those that used interactive computer technology to provide recommendations and immediate feedback of personally tailored information, were the most effective in improving patient outcomes (51). A randomized trial using electronic medical record (EMR) decision support in primary care found improvement in A1C (52), and a cluster randomized trial of a QI program found that the provision of a clear treatment protocol—supported by tailored postgraduate education of the primary care physician and case coaching by an endocrinologist—substantially improved the overall quality of diabetes care provided, as well as major diabetes-related outcomes (50). Incorporation of evidence-based treatment algorithms has been shown in several studies to be an integral part of diabetes case management (10,26,30,31). Even the use of simple decision support tools, such as clinical flow sheets, have been associated with improved adherence to clinical practice guidelines for diabetes (53).

Clinical information systems

Clinical information systems (CIS) that allow for a population-based approach to diabetes assessment and management, such as EMRs or electronic patient registries, have been shown to have a positive impact on evidence-based diabetes care (10,12,54,55). Practice-level clinical registries give an overview of an entire practice, which may assist in the delivery and monitoring of patient care. In addition to providing clinical information at the time of a patient encounter, CIS also can help promote timely management and reduce the tendency toward clinical inertia (56). Provincial- and national-level registries are also essential for benchmarking, tracking diabetes trends, determining the effect of QI programs, and for resource planning.

Other quality improvement strategies

Audits and feedback generally lead to small but potentially important improvements in professional practice and seem to depend on baseline performance and how the feedback is provided (57). Facilitated relay of information to clinicians may include electronic or web-based methods through which patients provide self-care data and the clinician reviews have been shown to improve care. Ideally, this should occur in case management with a team member who has prescribing or ordering ability (12). Physician and patient reminders also have shown benefit (12,50).


Environmental factors, such as food security, the ability to lead an active lifestyle, as well as access to care and social supports, also impact diabetes outcomes. Although community resources have not traditionally been integrated into care, community partnerships should be considered as a means of obtaining better care for patients with diabetes. For example, in addition to the diabetes health team, peer- or lay leader-led self-management groups have been shown to be beneficial in persons with type 2 diabetes (58,59).

Health systems

Support for diabetes care from the broader level of the healthcare system, such as the national and provincial systems, is essential. A number of provinces have adopted an expanded CCM (9)that includes health promotion and disease prevention (13). Many provinces and health regions also have developed diabetes strategies, diabetes service frameworks and support diabetes collaboratives. Some trials on diabetes-specific collaboratives have been shown to improve clinical outcomes (22,50,60), although a recent meta-analysis on continuous QI failed to show benefit (12).

Provider incentives represent another area of health system support. Some provinces have added incentive billing codes for patients with diabetes so that providers can be financially compensated for the use of flow sheets as well as time spent collaborating with the patient for disease planning (61). Pay-for-performance programs, which encourage the achievement of goals through reimbursement, are more commonly used outside of Canada. To date, these programs have had mixed results (62–64). Various payment systems also have been studied, but it is still unclear which of these may improve diabetes outcomes (65,66). Incentives to physicians to enroll patients and provide care within a nation-wide disease management program appears to be effective (23), as does infrastructure incentive payments that encourage the CCM (16). A meta-analysis that included physician incentives as a QI has shown mixed results for improved outcomes (12).


Although not a specific element of the CCM, telehealth technologies may help facilitate many components of this model. These technologies may be used for conferencing or education of team members; telemonitoring of health data, such as glucose readings or BP; disease management via telephone or internet; or teleconsultation with specialists. Telehealth also appears to be effective for diabetes self-management education and has been associated with improvements in metabolic control and reductions in CV risk (67). One RCT and 2 systematic reviews of telemonitoring of various disease management parameters, ranging from blood glucose results to foot temperature, found improved outcomes with telemonitoring, such as A1C lowering, a lower incidence of foot ulcerations and better QOL (4,68,69). These benefits were noted regardless of whether the teleconsultation was asynchronous or synchronous (69).


  1. Diabetes care should be proactive, incorporate elements of the chronic care model (CCM), and be organized around the person living with diabetes who is supported in self-management by an interprofessional team with specific training in diabetes [Grade C, Level 3 (6,23)].
  2. The following quality improvement strategies should be used, alone or in combination, to improve glycemic control [Grade A, Level 1 (12)]:
    • a) Promotion of self-management
    • b) Team changes
    • c) Disease (case) management
    • d) Patient education
    • e) Facilitated relay of clinical information
    • f) Electronic patient registries
    • g) Patient reminders
    • h) Audit and feedback
    • i) Clinician education
    • j) Clinician reminders (with or without decision support)
  3. Diabetes care management by an interprofessional team with specific training in diabetes and supported by specialist input should be integrated within diabetes care delivery models in the primary care [Grade A, Level 1A (12,21)] and specialist care [Grade D, Consensus] settings.
  4. The role of the diabetes case manager should be enhanced, in cooperation with the collaborating physician [Grade A, Level 1A (12,21)], including interventions led by a nurse [Grade A, Level 1A (29,30)], pharmacist [Grade B, Level 2 (34)] or dietitian [Grade B, Level 2 (70)], to improve coordination of care and facilitate timely diabetes management changes.
  5. As part of a collaborative, shared care approach within the CCM, an interprofessional team with specialized training in diabetes, and including a physician diabetes expert, should be used in the following groups:
    • a) Children with diabetes [Grade D, Level 4 (71)]
    • b) Type 1 diabetes [Grade C, Level 3 (46)]
    • c) Women with diabetes who require preconception counselling [Grade C, Level 3 (72–74)] and women with diabetes in pregnancy [Grade D, Consensus]
    • d) Individuals with complex (multiple diabetes-related complications) type 2 diabetes who are not reaching targets [Grade D, Consensus]
  6. 6.Telehealth technologies may be used as part of a disease management program to:
    • a) Improve self-management in underserviced communities [Grade B, Level 2 (67)]
    • b) Facilitate consultation with specialized teams as part of a shared-care model [Grade A, Level 1A (69)]

CCM, chronic care model.


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