Organizing Diabetes Care for Primary Care Providers with the 5 Rs

Quality Improvement Strategies

Dr. Lee practices with 4 other primary care providers in a suburb of a large city. The practice also draws their patients from a surrounding rural area. Though in a primary care network, the practice does not have diabetes education support, though does have a chronic disease nurse for patient case management (case management). Additionally, the practice does have a relationship with the local Diabetes Education Centre (DEC) as a resource, plus a link to pharmacies in the area that include Certified Diabetes Educator (CDE) pharmacists.

Dr. Lee saw Mary for the first time for a Pap test and general review. She had recently moved to the area and had no specific complaints. The physician noted several risk factors for diabetes including her age (52), a history of gestational diabetes plus a family history of diabetes and obesity.

According to the Diabetes Canada's Clinical Practice Guidelines, Dr. Lee knew she should be screened for diabetes. Dr. Lee ordered a fasting blood sugar which was 9.0 mmol /L. Dr. Lee knew a second confirmatory test was required because the CDA guidelines for screening were imbedded in the Electronic Medical Record (decision support tool). Mary had a second confirmatory test; an A1C that was 8.7%. Based on these screening test results, Mary was given the diagnosis of diabetes. (Recognize)


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

To achieve the best outcomes, Dr. Lee knows that Mary will need a variety of supports and will need to learn how to self-manage her diabetes to achieve optimal outcomes (self-management support).

The first support to help Mary is to set regular diabetes-focused visits with her primary care provider. To help organize these regular visits, Dr. Lee has a list (Registry) of the patients in his practice who have diabetes, through the practice management part of the EMR (Dr. Lee’s colleagues have paper charts and a spread sheet to identify their patients with diabetes). Using a Registry, Dr. Lee can assess his practice and understand how practice changes will help manage his patients with diabetes. As well, Dr. Lee’s registry will ensure Mary is Recalled in a regular and systematic fashion for her diabetes-focused appointments, and will remind Dr. Lee to follow-up with foot exams, eye exams and blood work (patient and clinician reminders).


Develop a registry or a method of tracking all your patients with diabetes.


Develop a system to remind your patients and caregivers of timely review and reassessment of targets and risk of complications.

The other essential support for Mary is for her to learn about her diabetes and become an active lead and participant in her diabetes care. This learning and active participation requires Self-Management Education (SME) and support from other diabetes healthcare providers. By adding other healthcare provider members to Mary’s diabetes team, Dr. Lee knows she will get better results and feel better about her diabetes (Resource). So, Dr. Lee refers Mary to the local Diabetes Education Program (DEP), where she will have the opportunity to see a nurse educator as well as a dietitian, who are both diabetes educators. As a result of the referral, Mary attends several diabetes education classes to engage in collaborative diabetes education. As well, Mary receives support and care in the primary care practice by Dr. Lee and the chronic disease nurse. The support that Mary receives from the DEP, plus follow-up visits with Dr. Lee and the chronic disease nurse, together help Mary set goals and problem-solve so that she has the best opportunity to learn and manage her diabetes (self-management support).


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

Six months later, Mary’s A1C had improved and was 6.4%. Over the next two years, she regularly attended her diabetes-focused visits, and worked to keep her A1C and other risk factors at target. As more time passed, Mary missed her next appointment with Dr. Lee, and subsequently, a “task” prompt appeared in the EMR / registry to remind the chronic disease nurse to call Mary and remind her of her missed appointment (clinical information systems / recall). Mary explained that she missed her appointment because of transportation problems, and that despite taking all her medications and adhering to her lifestyle changes, she had a rise in her blood sugars. During the call, she gave the nurse her most recent blood glucose (BG) values from her meter, and the nurse communicated the BG numbers to Dr. Lee (facilitated relay). Following this, Mary went to see her pharmacist to fill her prescription. The pharmacist did a point-of-care A1C, because Mary said she was not able to get to the laboratory for her A1C. The A1C was 10.2% and the pharmacist sent this result to Dr. Lee (facilitated relay). Dr. Lee reviewed Mary’s elevated A1C and BG numbers and heard from the chronic disease nurse that Mary has experienced transportation issues (facilitated relay).


Facilitate information sharing between the person with diabetes and team members for coordinated care and timely management change.

With all of this information at hand, Dr. Lee arranged for Mary to attend a group evening visit (self–management) and added a new medication to Mary’s routine.


Roll-over Quality Improvement Strategies to see definitions. Quality Improvement Strategies as found in Table 1 in Organization of Care chapter.


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