Table 2 Chronic Care Model – conceptual framework for MDETs in primary care

Organized integrated patient care

· Diabetes self-management support is being offered in PCPs’ offices for patients with diabetes.

i. Examine the effect of MDETs on patient clinical outcomes.

· An opportunity is created to promote knowledge exchange and capacity between PCPs and MDETs/DEPs by working together to provide better care for patients in primary care.

ii. Evaluate the effect of MDETs on the quality of care delivered to patients by PCPs.

iii. Examine the effect of MDETs on physician referral and patient utilization of DEPs.

iv. Assess the implementation process of the MDET and the degree of IPC between PCPs and MDETs across primary care sites.

Community linkages

· An opportunity is created to promote knowledge exchange and capacity between PCPs and MDETs/DEPs by working together to provide better care for patients in primary care.

iii. Examine the effect of MDETs on physician referral and patient utilization of DEPs.

iv. Assess the implementation process of the MDET and the degree of IPC between PCPs and MDETs across primary care sites.

Patient self-management support

· Diabetes self-management support is being offered in PCPs’ offices for patients with diabetes.

i. Examine the effect of MDETs on patient clinical outcomes.

Provider decision support

· An opportunity is created to promote knowledge exchange and capacity between PCPs and MDETs by working together to provide better care for patients in primary care.

i. Examine the effect of MDETs on patient clinical outcomes.

· A communication tool will be used to exchange patient recommendations and treatment plans between MDETs and PCPs.

ii. Evaluate the effect of MDETs on the quality of care delivered to patients by PCPs.

· Regular case conferences have been agreed upon between MDETs and PCPs after patients’ visits.

iii. Examine the effect of MDETs on physician referral and patient utilization of DEPs.

· Hard copy of clinical practice guidelines and Diabetes Flow Sheet for Diabetes Management for PCPs.

iv. Assess the implementation process of the MDET and the degree of IPC between PCPs and MDETs across primary care sites

Delivery system re-design

· Diabetes self-management support is being offered in PCPs’ offices for patients with diabetes.

i. Examine the effect of MDETs on patient clinical outcomes.

· An opportunity is created to promote knowledge exchange and capacity between PCPs and MDETs/DEPs by working together to provide better care for patients in primary care.

ii. Evaluate the effect of MDETs on the quality of care delivered to patients by PCPs.

iii. Examine the effect of MDETs on physician referral and patient utilization of DEPs.

iv. Assess the implementation process of the MDET and the degree of IPC between PCPs and MDETs across primary care sites.