Table 1.

Chronic Care Interventions by Educational and Quality Improvement Emphasis

Intervention emphasis
CCM component	Educational activities	Quality improvement activities
Community linkages		● Identification of one ophthalmologist to join team
Self-management support	● Resident workshops for self-management goal (SMG) training and motivational interviewing	● Use of EMR messaging for SMG follow-up
		● Use of SMG form
Delivery system design		● Staff involvement in patient outreach
		● Monofilament testing protocol
		● Monthly team meetings
		● Expedited rescheduling of patients with missed appointments
		● Redesign of scheduling system to allow appointments three months into the future
		● System of identifying collaborative patients and interventions that are due
Decision support	● Didactics on diabetes management	● Creation of resident teaching protocol for insulin and glucometer use
	● Creation of patient teaching protocol for insulin and glucometer use
Clinical information systems	● Monthly review of provider performance reports	● Diabetes patient registry
		● Diabetes flow sheet with embedded guidelines
Integration of CCM components	● Creation of multi-disciplinary diabetes teaching clinic