Activity	Collaboration Examples
Individual services	“The program reviews the Certifications of the 32 Diabetes Self-Management Training (DSMT) Sites, collects sites’ CQI objectives, and DSMT participant goals (set and accomplished). Oversees and administers the New Instructor Program for all DSMT instructors in the State.”
Delivery system	“We have implemented a program that assists primary care health care practices to implement components of the chronic care model to become NCQA-recognized patient-centered medical homes.”
	“[Changed] EHR so that a fully electronic process for identifying, offering assistance, and referring those that wanted assistance to quit tobacco was developed. Further, the [cessation] counselor treating the patient electronically sends a follow up report back to the referring provider.”
Decision supports	“Health systems change and infrastructure building to ensure patients are screened for CRC. Examples include office policy development, building EHR cancer registries, and developing patient reminders.”
	“[State] set up a Chronic Disease Collaborative that involves members across various sectors including health care systems to address common goals, objectives, and strategies. This opportunity allows members to collaborate and share information and resources.”
Information systems	“We work with the largest health insurance provider to implement a free clinical information system. This free Web-based system . . . allows the providers to monitor [risk factors] . . . see at a glance missed care opportunities and can generate letters to send to patients to encourage them to call the office for an appointment. We currently have over 70% of the state providers enrolled in the system.”
	“We are currently working on a collaborative effort to build a network of electronic records access to help improve the surveillance aspects of chronic disease in [state] while linking this with Medicaid. There is a lot of coordination happening to adopt this in our state.”
Community	“A centralized referral system has been implemented with patient navigation services to assist the patients referred from the practices to [12 community evidence-based lifestyle and disease management programs].”

Abbreviations: CQI, continuous quality improvement; CRC, colorectal cancer; EHR, electronic health record; NCQA, National Committee for Quality Assurance.