Table 1.

Population care practices surveyed.

Practice	Definition	Items
Health System Organization
Financial Incentives	Amount of physician salary at risk, subject to assessment of performance on population care quality indicators.	4
Provider Feedback	Reports to providers about performance and degree of blinding to all providers.	40
Self-Management Support
Patient Action Plans	Individual goal setting supported by action plans including needs assessment, personalization, and regular clinician review.	4
Patient Education	Education and support services based on self-management principles in a variety of formats.	35
Delivery System Design
Defined Care Path	An explicit protocol or model guides population care.	4
Risk Stratification	Use of an algorithm to stratify patients by risk level and determine the level of proactive care provided.	4
Outreach/Follow-Up	Proactive, planned care.	19
Inreach	Customized reminders for patients of needed care whenever they present for service.	5
Care Coordination	Processes and structures supporting effective patient care handoffs, including explicit protocols and accountabilities.	6
Cultural Competence	Care tailored to the needs of major racial, ethnic, and cultural groups.	15
Team Accountability	Accountability for patient care vested in care teams rather than individuals.	1
Decision Support
Guideline Distribution and Training	Distribution of evidence-based guidelines and clinician training on guideline content, including electronic availability, continuing medical education, and inter-provider communications.	5
Provider Alerts	Customized, context-sensitive paper-based or electronic alerts reminding providers of appropriate care for individual patients and groups of patients.	28
Clinical Information Systems
Registry	Completeness and quality of a registry or database of key indicators for all patients with diabetes.	72
Electronic Medical Record	Availability and comprehensiveness of clinical data during patient visits.	36