The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making.


Introduction
Diabetes is a major cause of heart disease and stroke among adults in the United States and is the leading cause of nontraumatic lower-extremity amputations, new cases of blindness, and kidney failure (1)(2)(3). In 2010, the Centers for Disease Control and Prevention reported that 25.6 million, or 11.3%, of US adults aged 20 or older had diagnosed or undiagnosed diabetes (1). Comprehensive models of care, such as the original Chronic Care Model (CCM) (4,5), advocate for evidence-based health care system changes that meet the needs of growing numbers of people who have chronic disease. CCM was developed (4,5) to provide patients with self-management skills and tracking systems. The model represents a well-rounded approach to restructuring medical care through partnerships between health systems and communities.

Data extraction
As recommended by the Centre for Reviews and Dissemination systematic review guidelines (8), we created the following categories to systematically assess the 16 studies and gain an understanding of the methods used and the outcomes associated with CCM application: study design, sample size, setting, participant demographics, primary and secondary outcomes measured, data collection instruments used, statistical tests used, and major findings. We determined which of the 6 CCM components had been applied to each intervention and how the component(s) had been applied. We then qualitatively assessed the outcomes of each component that was applied in each study. The study selection process was conducted by 1 author (K.D.) and then repeated by the same author to ensure accurate selection; any discrepancies were analyzed and resolved on the basis of the inclusion and exclusion criteria. The same author (K.D.) extracted the data. Another author (M.S.) critiqued the data to identify any inconsistencies between data presented in the studies and the data extracted for the review, posed questions for further clarification on all extracted

Self-management support
We found that diabetes self-management education (DSME) generally improved psychosocial and clinical outcomes in patients with diabetes. Twelve of 16 studies administered individual DSME sessions (10-12,14-21,24), and 9 studies (10-12,15-17,19,20,24) administered group sessions using both group-and individual-level approaches. Facilitators, such as Certified Diabetes Educators (CDEs) or nurses, provided instruction on various topics, such as medication compliance, goal setting, foot care, and interpretation of laboratory results (10-12,14-17,20,24). Follow-up telephone calls allowed clinicians to monitor patient progress toward meeting diabetes-management goals that were set during individual office visits (10,15,18,21). For example, Schillinger et al (15) found that weekly automated (prerecorded) tailored telephone calls from nurses were associated with improvements in interpersonal processes of care, physical activity and function, and slightly better metabolic outcomes (eg, HbA1c, blood pressure, cholesterol). Lyles et al (23) found that the use of a secure e-mail connection and a smartphone to upload glucose readings via a wireless Bluetooth device allowed some participants to feel better connected with their nurse case manager. However, some participants found this communication system to be unstructured and preferred regular interaction (eg, face-to-face) with their nurse case manager; some participants found the smartphones to be frustrating because of technical difficulties associated with these unfamiliar technologies (23). Other studies reported that computer-based interactive diabetes self-management training modules and toolkits were supplemented by a "diabetes passport" (19) or "diabetes care record" (20) that listed goals, action plans, and laboratory results so that patients and providers could monitor performance and progress in diabetes care.

Decision support
Specialized decision support services for diabetes care were provided to PCPs (eg, endocrinologists) and nurse practitioners via telephone and e-mail (18), problem-based learning meetings (11,12,14,16,17), and telemedicine technology (13). Individual patient reports were also provided to health care teams for reviewing clinical trends (eg, HbA1c, blood pressure, lipids) and initiating clinical responses to laboratory results (eg, medication adjustments) (9,10,20,23). Training PCPs on evidence-based guidelines and methods for implementing CCM resulted in improved PCP adherence to clinical guidelines, including the American Diabetes Association (ADA) Standards of Care (10-12,14,16,17) and Institute for Clinical Systems Improvement (ICSI) Clinical Guidelines for Hypertension, Diabetes, and Hyperlipidemia (18). In several studies (10-12,14,16-18), this training was associated with improved diabetes knowledge among patients and improved levels of HbA1c and high-density lipoprotein (HDL) cholesterol.

Delivery system design
Implementation of ADA standards of care (10-12,14,16,17) and ICSI clinical guidelines (18) resulted in innovative diabetes care delivery in PCP offices. For example, ADA standards require that people with diabetes receive DSME to "optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner" (25). To address barriers to care, such as poor diabetes knowledge, low awareness of educational service accessibility, and lack of psychosocial support (10,26), PCPs streamlined DSME services by offering "diabetes days" and planned visits exclusively for people with diabetes (10-12,14-21,24). Instituting these programs in PCP offices allowed for better communication between CDEs, PCPs, and patients, which contributed to lower HbA1c levels (10-12,18,20,24); better adherence to medication and adjustment processes; and stronger support networks located in more personalized settings (10,11,(15)(16)(17)19,20,24). One study (12) even noted that providing DSME programs in PCP offices instead of hospital settings resulted in a 2-to 3-fold increase in the number of patients reached with diabetes education.

Community resources and policies
Seven studies (11,12,16-18,20,24) specified strategies for using community resources and forming public policy. Collaborations between community leaders and physicians (11,16,17) and between pharmaceutical companies and health plans (20) led to support for PCP training sessions on how to use CCM for diabetes management. Hospital and PCP collaborations within the community, such as partnerships between the University of Pittsburgh Medical Center and western Pennsylvania community hospitals and PCP offices (12), provided greater access to funding, information systems, and administrative support for CCM implementation (11,12,16,17).

Discussion
The findings of these studies contribute to a qualitative understanding of the relationship between the application of CCM components and diabetes outcomes in US primary care settings. Although the original CCM has been critiqued for not adequately meeting the needs of diverse patient populations with diabetes (7), our systematic review supports the idea that CCM-based interventions are generally effective for managing diabetes in US primary care settings.
One meta-analysis (27) determined that no single component of the CCM was imperative for improved outcomes. However, it is important to determine the combination of components that will likely produce optimal patient and provider outcomes. Our review suggested that incorporating multiple components together in the same intervention can help facilitate better CCM implementation (eg, using the decision-support component to train providers on guidelines such as the ADA Standards of Care and using the delivery system design component to remodel the care delivery process to provide self-management support through DSME in PCP offices).
In several studies, organizational leaders in health care systems initiated system-level reorganizations that facilitated more comprehensive and coordinated diabetes care. Changing staff roles and responsibilities to more efficiently treat diabetes was 1 strategy that produced clinical benefits. Reorganized care can also support better training programs for patients to help them self-manage diabetes. Future system-level CCM reorganizations should create clear access points for providers to intervene with patients who are at risk for diabetes complications. Some organizations have already begun to do so. For example, the Rockwood Clinic Foundation revised its mission statement to include fundraising for research and development in new methods of chronic care delivery, which has resulted in increased funding for training materials, glucometers, blood pressure monitors, and laboratories (20).
In several studies (10-12,14,16-18), providing administrative support to train PCPs in implementing evidence-based care was associated with improved patient engagement that led to positive health outcomes. Future studies should examine the effects of continuing education for ADA Standards of Care and ICSI clinical guidelines on CCM decision support among providers. It is important to determine whether provider training delivered through telecommunication and distance learning technologies can provide ample decision-support training to PCPs. Another area worth investigating is whether the longitudinal use of decision support in different primary care practice settings (eg, private practices, community health centers, hospitals) improves patient outcomes.
Delivery system design was identified as an important strategy for integrating DSME into primary care settings through addressing patient barriers to care such as accessibility to DSME and availability of staff to assist with diabetes care (10). Our review supports the idea that DSME improves psychosocial and clinical outcomes. DSME fostered learning about proactive diabetes self-care practices and self-management skills. When ADA-accredited DSME occurs in primary care settings, PCPs are able to provide patients with personalized access to CDEs, who are likely funded through third-party health insurers (12). Offering DSME in primary care settings, rather than solely hospital settings, enhances the reach of such programs in a more intimate, socially supportive venue. Future DSME for primary care patients should continue to cover the ADA content areas (28) for diabetes self-management, and strategies for delivering DSME should be evaluated by assessing the comparative effectiveness of group-and individual-level DSME approaches.
Only 1 study in our review (24) conducted weekly, skill-based learning sessions for racial/ethnic minority groups on healthful cooking modifications for traditional foods and snacks. This type of culturally appropriate self-management support was associated with a greater number of participants who had an HbA1c measurement of less than 7% and a fewer number of participants who had an HbA1c measurement of greater than 10% (24). Other culturally tailored non-CCM interventions (29) have demonstrated larger absolute reductions in HbA1c than nontailored interventions. Given the large number of racial/ethnic minority populations in the United States who are at high risk for type 2 diabetes (eg, African Americans, Hispanics, American Indians, Asian Americans, Pacific Islanders) (30), future research should focus on culturally tailored DSME in primary care settings. Cultural factors (eg, food preparation, views of illness) should be considered when designing, implementing, and evaluating DSME for these underserved groups (31). It is also noteworthy that none of the reviewed studies addressed the needs of pediatric patients diagnosed with either type 1 or type 2 diabetes. Diabetes is becoming more common in children and adolescents (32); Rapley and Davidson (33) have advocated for the adoption of CCM programs aimed at adolescent patients with diabetes to help bridge the gap between pediatric and adult care.
More personalized, patient-centered interactions (eg. individual office visits) help patients and providers set behavioral and clinical goals that can be monitored through clinical information systems. Many studies (9,10,12,14,18,20, 21,23,24) used disease registries and electronic medical records to establish patient goals, monitor patient progress, and determine lapses in patient care. Assimilating clinical information systems into user-friendly, portable digital technologies (ie, smartphones, iPads) may enable patients and providers to view and respond to laboratory results more regularly. For older populations of chronic disease patients (the age group sampled in most of the reviewed studies), training programs on the use of digital technologies for diabetes self-management may reduce the anxiety and barriers to access that may currently exist (23,34). Involving patients in exploratory focus groups to inform the development of assistive technologies can customize educational technology and address usability concerns among unique patient populations (35). Future studies on diabetes self-management support within the broader CCM framework should attempt to refine the use of information and communications technologies to empower, engage, and educate patients (36).
Finally, community-level partnerships pooled human and fiscal resources to provide diabetes management services (11,12,16-18,20,24). However, strategies for using community resources and developing policies were described in only 7 studies. A meta-analysis (27) also found that few studies addressed the community resources and policies component of CCM. More public-private partnerships need to be developed between providers and community organizations to address barriers to care and explore culturally appropriate community-based services (eg, cooking classes, exercise programs, nutrition counseling, self-monitoring assistance) for underserved populations and neighborhoods. Other models have sought to improve the community resources and policies component of the CCM. The Innovative Care for Chronic Conditions (ICCC) model espoused by the World Health Organization (33,37) is comparable to the Expanded Chronic Care Model proposed by Barr and colleagues (7); it introduces prevention efforts, social determinants of health, and enhanced community participation as core components of chronic disease care. The ICCC has a larger focus on supporting "positive policy environments" (ie, partnerships, legislative frameworks, human resource allocation, leadership, and financing) in community and health care organizations (33,37). Future studies should investigate how different derivations of CCM components contribute to changes in diabetes care within primary care settings.
This study had several limitations. We used only a few search terms, so all relevant studies may not have been identified. Only 1 person selected the studies for inclusion in our review. Future studies should use the multiple-rater approach for study selection and data extraction as outlined by the Centre for Reviews and Dissemination systematic review guidelines (8). We did not conduct a meta-analysis because we did not have access to primary data, and the variability in study design did not allow us to pool data. Future research could include a meta-analysis of data (27) from randomized controlled trials to evaluate the methodological quality of quantitative studies that have tested the effectiveness of CCM for managing diabetes.
In conclusion, our study provides evidence that CCM is effective in improving the health of people who have diabetes and receive care in primary care settings. The model accounts for health services at various levels in the diabetes care process. Positive clinical outcomes have been cited as indicators of CCM's success in diabetes management (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). Far less emphasis has been placed on measuring the process outcomes of CCM that help lead to functional and clinical improvements. Process outcomes (eg, self-efficacy for disease management and clinical decision making, perceived social support, knowledge of diabetes self-care practices) are all indicators that need to be assessed. These assessments could enable health care administrators and professionals to determine how CCM could become further integrated into primary health care initiatives in diabetes.

Statistical tests used
Univariate analyses to determine differences between baseline and 12-month follow-up, paired t tests used for continuous data and McNemar test for categorical data. Between-and within-group analysis of variance used to examine differences among 3 study groups.
Major findings Patients in the CCM group had significant increases in blood glucose self-monitoring at 12-month follow-up (P <.001). These outcomes were sustained at 3-year follow-up. HbA1c values declined significantly in the CCM group (7.6% to 7.0%, P = .008). A significantly greater (P = .04) proportion of participants in the usual-care group (54.2%), compared to the CCM (13.3%) and providereducation-only (38.9%) groups, had treatment intensification for glycemia.

Study setting
Suburban and urban primary care practices.

Participant demographics
Mean age, 57.2 y.

Primary outcomes measured
Patient HbA1c levels; number of ADA-recognized programs; proportion of patients who received DSME in primary care practices vs hospital-based programs; and reimbursement for CDE.

Secondary outcomes measured
None reported.

Instruments used
Laboratory results. The Medical Archival Retrieval System allowed for reimbursement and usability monitoring.

Statistical tests used
Student t test; Pearson χ test; Multilevel model for change.
Major findings Number of ADA-recognized programs grew from 3 to 21 through decision support. A 2-to 3-fold greater proportion of patients reached when DSME was available at primary care practices compared to hospital-based programs. Having DSME programs at primary care practices resulted in improvements in HbA1c levels and better communication and use of resources among PCPs and CDEs. Patients reported comfort with location and ease of approaching CDEs.

Smith et al (13)
Study design (no. of participants) Physicians and their patients were randomized to the control or intervention group (clustered randomization). Physicians and patients were nonblinded, and outcome assessors and data analysts were blinded to allocation (n = 639).

Statistical tests used
Generalized linear models.
Major findings No significant differences in metabolic outcomes and coronary artery disease risk were found between control group and group receiving the virtual consultation.
Study setting Primary care clinics in Pennsylvania.

Primary outcomes measured
Percentage of patients achieving goals for HbA1c, blood pressure, and LDL cholesterol.

Secondary outcomes measured
Number of patients with depression; rates of eye and foot examinations; nephropathy assessment; cost-effectiveness; psychological and behavioral outcomes.

Instruments used
Audit of Diabetes Dependent Quality of Life survey, Problem Areas in Diabetes scale, Diabetes Treatment Satisfaction Questionnaire, Summary of Diabetes Care Activities, and the Provider Satisfaction Inventory.

Statistical tests used
Logistic regression for binary outcome measures (eg, success in meeting HbA1c, blood pressure, and LDL cholesterol goals); generalized estimating equations for longitudinal data; repeated measures analysis of variance for continuous outcomes (eg, HbA1c, systolic blood pressure, lipids).
Major findings Study in progress, so other than baseline data, outcomes have not been reported. Baseline survey scores of the patient population showed a high level of depression and a slightly positive effect of diabetes on self-confidence and that diabetes had most negative effect on enjoyment of vacations and on enjoyment of food and drinks.

Schillinger et al (15)
Study design (no. of participants) Practical clinical trial with 3 arms: interactive weekly automated telephone self-management support with nurse follow-up (ATSM), group medical visits with physician and health educator facilitation (GMV), and usual care; random assignment to groups (n = 339).

Primary outcomes measured
HbA1c, non-HDL cholesterol, and blood pressure levels at 3-year follow-up.

Secondary outcomes measured
Sustained outcomes in quality of well-being, self-monitoring of blood glucose.

Instruments used
Modified Diabetes Care Profile; World Health Organization (Ten) Quality of Well-Being Index.

Statistical tests used
Paired t test; McNemar test.

Major findings
HbA1c improvements observed at 1-year follow-up were sustained in 8 of 12 participants in CCM group at 3-year follow-up, whereas the provider-education-only group and usual-care group remained constant from baseline. Mean non-HDL cholesterol values and systolic and diastolic blood pressure improved in all groups, although the only statistically significant improvement was in diastolic blood pressure in the CCM group (P=.04).
Study setting General, family, and internal medicine practices (n = 24) in Pittsburgh, Pennsylvania.

Primary outcomes measured
Provider-perceived patient barriers to care; adherence to ADA standards of care; patient HbA1c, blood pressure, non-HDL cholesterol levels; height and weight; knowledge and empowerment levels; diabetic, lipid and blood pressure treatment intensification.

Secondary outcomes measured
None reported.

Instruments used
Barriers to Diabetes Care Instrument, Diabetes Empowerment Scale, and the World Health Organization (Ten) Quality of Well-Being Index.

Statistical tests used
Forward linear regression, general linear regression.

Major findings
The CCM group had the largest decrease in HbA1c values (−0.6%, P = .008) compared with no significant reduction in the provider-education-only and usual-care groups, with no significant Study Summary Data change in treatment intensification. Having higher baseline HbA1c values, older age, and being in the CCM group were each associated with improved glycemic control.
Study setting Free medical clinic for uninsured patients.

Primary outcomes measured
Clinically significant improvement for patients in at least 1 chronic disease (ie, 1-stage reduction in blood pressure for hypertensive patients, decrease of at least 1% of HbA1c for patients with diabetes, reduction of risk group in LDL cholesterol for patients with hyperlipidemia).

Secondary outcomes measured
Change in mean arterial pressure, change in HbA1c, change in LDL cholesterol.

Instruments used
Laboratory results, clinical measures.

Statistical tests used
Paired t test.
Major findings 64% of patients with hypertension improved by at least 1 stage; 53% had a 1% reduction in HbA1c levels; 58% of patients with high LDL cholesterol improved by 1 risk group; mean arterial pressure, mean HbA1c, and mean LDL cholesterol showed significant improvements (P < .001); CCM was found to be a successful template for delivering chronic care to uninsured patients in a free medical clinic.

Study setting
Walk-in urgent care clinic for uninsured patients.

Primary outcomes measured
Health beliefs, self-reported dietary habits, weight, HbA1c, systolic and diastolic blood pressure, LDL cholesterol, patient satisfaction with clinic.

Secondary outcomes measured
None reported.

Instruments used
Laboratory results, self-reported dietary habits and health beliefs, patient satisfaction with clinic rated on scale of 1 to 10.

Statistical tests used
McNemar test for dichotomous data, Wilcoxon signed rank test for ordinal data, and paired t test for continuous data.
Major findings Mean change in lowering HbA1c levels was significant (P <. 001); systolic blood pressure decreased on average by 9 mm Hg; diastolic blood pressure decreased on average by 5 mm Hg; LDL cholesterol decreased on average 16 mg/dL; 80% of patients rated satisfaction with clinic as 8 or higher.

Benedetti et al (20)
Study design (no. of participants) Natural experiment with comparison group; 11 participating providers had 698 patients; 19 nonparticipating providers had 1,300 patients.

Study setting
Private-sector, fee-for-practice, multispecialty group practices. Major findings Favorable adherence to eye examinations and blood pressure control associated with increased time (in years) of provider participation using CCM (P < .05). Similar trends found in patients taking acetylsalicylic acid, having foot examinations, setting goals for self-management, having annual HbA1c test, having an HbA1c < 8.0, and having an annual urine protein test. 78% of providers expressed satisfaction with their collaborative work after using CCM; only 28% expressed satisfaction before implementing CCM.
Study setting University-based care delivery system.

Participant demographics
Participants had an established diagnosis of type 2 diabetes (age and sex were not reported).

Primary outcomes measured
Blood pressure; HbA1c levels; documentation and follow-up of goal setting; eye and foot examinations; medical residents receiving/reviewing/discussing registry reports; medical residents learning and demonstrating self-management support strategies.

Instruments used
Laboratory results.

Statistical tests used
None reported. Percentage improvement was calculated.
Major findings Participants showed improvement in performance measures, such as initiating goal setting, receiving eye and foot examinations, seeking vaccinations, attaining blood pressure goals, and adhering to medication instructions, but they showed nonsignificant improvement in HbA1c.

Major findings
The low-cost and time-efficient interventions used in this study (ie, developing a protocol for foot examinations, training patients and medical assistants in foot examination, and tracking patients for follow-up appointments) improved clinical outcomes (blood glucose, lipid, blood pressure, and foot examinations) of patients who had both diabetes and cardiovascular disease.
Study setting University of Washington general internal medicine clinic, Seattle, Washington.

Primary outcomes measured
Process measures: glucose readings and uploads, patient-provider e-mails.

Secondary outcomes measured
Participant satisfaction.

Instruments used
Qualitative interview guide.

Statistical tests used
Phenomenology to analyze participant's narratives; thematic coding; Atlas.ti version 5.2 used to analyze relationship between concepts and analyze codes across transcripts.
Major findings Study produced mixed results. Patients felt more aware of and engaged in their own care through monitoring their glucose, sharing their glucose readings with the nurse case manager, and communicating with the nurse case manager via the secure e-mail system; uploading glucose readings and receiving feedback was easy. However, half of the patients found the use of smartphones to be frustrating (unfamiliar technology). Using the Nintendo Wii to access electronic medical records was not useful (unfamiliar technology).
Study setting Community health center.

Primary outcomes measured
Glycemic control; patient participation in activities.

Secondary outcomes measured
None reported.

Instruments used
Laboratory results, participation data from registry.

Statistical tests used
Statistical analysis was not described.
Major findings HbA1c levels were consistent for 4 years before implementation of self-management activities.
Participants showed a decrease in HbAlc levels (mean HbA1c decreased from 8.6 to 8.0) after an   (9) Decision support Developed the Vermont Diabetes Information System to collect clinical information and provide flow sheets, reminders, and alerts to physicians and their patients with diabetes. The system also generates population reports so that physicians can view the progress of their patients with diabetes.
CCM is used as the framework; laboratories provide daily data feeds; algorithms provide automatic test interpretation; fax and mail are used for providers not easily reached by electronic networks; reports are formatted for accessibility and usability by patients and providers.

Siminerio et al (10)
Self-management support Participants and their family members met with team members for five 2-hour group sessions biweekly. Each group consisted of 5 to 10 participants who learned goal-setting strategies based on the empowerment approach, problem-solving skills, and behavioral change strategies.
Patients led the discussion according to individual needs, and the CDE facilitated the discussion to include ADA's 10 content areas.

Decision support
PCPs were trained by CDEs on ADA standards of care and implementation of guidelines.
Problem-based learning sessions were used to demonstrate implementation of guidelines into a plan of care.
PCPs completed routine examination and assessed complications during each visit.
Process delivery (HbA1c, lipid panel, blood pressure, urinalysis, dilated eye referral, foot examination, and use of monofilament) were to be recorded by PCPs.
Delivery system design "Diabetes days" were organized: on these days, CDEs were in PCP offices for routine office visits and DSME.

Piatt et al (11), Piatt et al (16), Piatt et al (17)
Health systemorganization of health care Principal investigator met with PCPs to determine needs.
Funding was obtained from local hospital foundation and parent hospital system.

Self-management support
Offered 6 weekly CDE-facilitated DSME sessions based on the University of Michigan DSME curriculum.
Monthly support groups focused on foot care, healthful cooking and recipe modification, alternative treatments, and problem-solving skills.
Used ADA diabetes education content areas.
Used empowerment approach during patient visits.

Decision support
Problem-based learning sessions were held for PCPs, led by an endocrinologist using diabetes management questions.
PCPs received training on ADA standards of care for people with diabetes.
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Study/Component
Application Decision support Nurse trained on ADA clinical care guidelines.
Delivery system design Case management, evidence-based care, cultural competency, improved provider interactions.

Clinical information systems
Penn State Institute for Diabetes and Obesity patient registry system was used to identify patients with uncontrolled diabetes (HbA1c >8.5), hypertension (blood pressure >140/90 mm Hg), or hyperlipidemia (low-density lipoprotein cholesterol >130 mg/dL). Nurses also entered patient information into the registry, and single-sheet patient reports could be generated from the registry to show self-care goals, patient's trends (eg, blood pressure, HbA1c, lipids, eye examination, aspirin use, foot examination), and alerts for issues to address during the patient's visit (eg, missed examination, abnormal laboratory results).

Schillinger et al (15)
Self-management support Patients had either interactive weekly automated telephone self-management support with nurse follow-up or monthly group medical visits with physician and health educator facilitation.

Stroebel et al (18)
Health systemorganization of health care Project was fully supported by the governing board of the Salvation Army Free Clinic.

Self-management support
Collaborative goal setting addressed self-monitoring and lifestyle modification by using a selfmanagement wheel to display components.
Nurses followed up with telephone calls to monitor progress toward goals.

Decision support
Used Institute for Clinical Systems Improvement Clinical Guidelines for Hypertension, Diabetes, and Hyperlipidemia.
Core physicians were advocates of guideline-based management.
Specialty expertise from a volunteer endocrinologist was consistently available by telephone or e-mail.
CDE met with patients who had diabetes.
Delivery system design Nurses interacted most with the patients, using evidence-based algorithms from the Institute for Clinical System Integration to provide patient care and manage medications.
Telephone and e-mail communication facilitated interaction between nurses, volunteer physicians and specialists (eg, endocrinologists). The volunteer physicians and specialists were available for consultation to manage challenging cases and questions (eg, difficult medication issues, questions directed to the physicians).
Medications were available at no cost to patients according to clinic policy and practices.

Clinical information systems
Secure, password-protected patient registry was created on Microsoft Excel and managed by a registered nurse.

Community resources and policies
Salvation Army Free Clinic was a product of community collaboration and the volunteer efforts of professionals and community laypersons.

Khan et al (19)
Health systemorganization of health care Clinic space was modified to provide services.
Staff were reorganized and retrained to provide chronic care.
Self-management support Educational materials were developed for patients with diabetes.
30-Minute interactive group sessions focused on dietary choices, exercise, weight loss, and self-monitoring.
Medications were reviewed in group setting; discussion focused on adherence.
Computer-based educational modules focused on diabetes self-management topics.