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
  • Highlights
  • 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.

Highlights of Revisions

  • In 2008, recommendations focused on patient self-management with the support of an interprofessional diabetes healthcare team. The newly revised recommendations now focus on the chronic care model (CCM) which includes elements beyond the patient and healthcare provider, including delivery system designs, self-management support, decision support, clinical information, the community and health systems.
  • Telehealth technologies are now also recognized.
  • A new Patient Care Flow Sheet (p. S350) has been developed.


  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 (1,2)].
  2. The following quality improvement strategies should be used, alone or in combination, to improve glycemic control [Grade A, Level 1 (3)]:
    • 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 (3,4)] 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 (3,4)], including interventions led by a nurse [Grade A, Level 1A (5,6)], pharmacist [Grade B, Level 2 (7)] or dietitian [Grade B, Level 2 (8)], 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 (9)]
    • b)Type 1 diabetes [Grade C, Level 3 (10)]
    • c)Women with diabetes who require preconception counselling [Grade C, Level 3 (11–13)] 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 (14)]
    • b)Facilitate consultation with specialized teams as part of a shared-care model [Grade A, Level 1A (15)]

CCM, chronic care model.

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.


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Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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