August 31, 2020 | 6 Best Practices to Deliver Measurable Outcomes for Diabetes Management

Establishing successful diabetes management depends on implementing strategies proven to improve clinical outcomes. These tactics must not only deliver productive interactions between your practice and patients to educate and support them in their lifestyle changes but ensure best practices are executed upon for this vulnerable population. A model that lends itself efficiently to improving the quality of diabetes care is chronic care management (CCM). With its proven framework in producing positive outcomes, we outline below how it can benefit both your practice and your diabetic patient population.


Team-Based Care

The success in helping patients better manage their diabetes relies on several tactics including implementing a team-based care approach. As a method that moves from delivering care reactively to more proactively, healthcare professionals from multiple disciplines can coordinate and develop customized care plans with planned visits. These comprehensive evaluations not only address the patients’ individual beliefs but should support patient autonomy and engagement with providers, which promotes their adoption of positive behavior changes, according to a study by Williams, 2016.

This tactic is especially effective in ensuring patients receive appropriate lab tests, become educated with self-management techniques, and prevent complications related to diabetes.

Because of the time and partnership invested in this practice, it can be the “most effective in managing the inherent complexity of the disease,” according to AJMC. Consequently, this type of care can improve patients’ diabetic outcomes including blood glucose level, diastolic blood pressure, and total cholesterol.

Studies show that when team-based care is applied to improving diabetes care, participants also had fewer hospitalizations and emergency department visits, according to the American Journal of Preventive Medicine.



Patient-Centric Care

Maintaining and improving a chronic condition like diabetes should focus on empowering patients in their healthcare decisions. By promoting a patient-centered care approach within its structure, CCM effectively involves patients in shared decision making. This leads to the patient becoming the final driver of healthcare decisions instead of the provider having all the authority, according to Patient-Centered Care in Type 2 Diabetes Mellitus.

When supporting patients’ in their diabetes management, it is essential to work with the individual and create goals based on their actions and how they experience their chronic conditions. This tactic includes “ongoing individual lifestyle and behavioral changes, engagement of the patient, and assessment of the patient’s level of understanding about the disease and level of preparedness for self-management,” according to American Diabetes Association.

When patients participate mutually in their healthcare, it leads to “increased patient satisfaction, improved patient-provider communication, and enhanced patient well-being,” according to Patient-Centered Care in Type 2 Diabetes Mellitus.


Self-Management Support and Education

Instituting effective diabetes management can ultimately depend on the patient’s ability and willingness to adopt healthier behaviors. Before engaging in healthier lifestyle choices, they must first feel supported and empowered to better manage their conditions. With consistent touchpoints, CCM providers can better “understand their patients’ needs and create the ideal environment for their care,” according to Future Medicine.

This way, they can provide appropriate education to patients on how to best pursue self-management and can also fundamentally improve their health literacy. Topics can include medication compliance, goal setting, and eating habits. Also, as the Chronic Care Coordinator (CCC) and patient share healthcare decisions, the CCC can keep track of their patients’ progress in meeting their diabetes-management goals.

By creating a personalized approach to self-management education based on patients’ needs, CCM providers can help drive participation in implementing lifestyle changes which can subsequently improve their quality of life with diabetes management. This can also lead to positive patient outcomes as stated in a trial by American Diabetes Association: “Because of more recommended preventive procedures and helpful patient education, patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits.”



Decision Support

A successful foundation for diabetes management must include decision support services. Since supporting positive patient behavior change coincides with adhering to effective care guidelines, consistently communicating with PCPs about these standards is necessary when implementing CCM. It leads to greater PCP adherence to clinical guidelines as well.

Since CCCs are continuously kept up to date on evidence-based guidelines for implementing CCM, it leads to “improved diabetes knowledge among patients and improved levels of HbA1c and high-density lipoprotein (HDL) cholesterol,” according to a study by Stellefson, 2013.

With these evidence-based guidelines integrated into daily clinical practice, CCCs can help improve patient-provider relationships, increase patient education and understanding of diabetes to increase patients’ improved adherence to self-care behaviors, according to a study by Williams, 2016. They can include settings goals, diet, blood sugar testing, and foot care.



Clinical Information Systems

Working with merged clinical information systems can assist with team-based care so each healthcare provider has access to electronic medical records. Based on the monthly interactions between patients and CCCs, providers can review the self-management goals created and see whether they’ve met their goals.

They can also “review detailed reports on laboratory and examination results and identify lapses in diabetes care (missed visits, laboratory appointments, and examinations),” according to a study by Williams, 2016. This type of tracking can help improve outcomes and provider response to clinical data.



Community Resources

Known as one of the nation’s most costly healthcare challenges, ongoing treatment for chronic illnesses makes up about 90% of the $3.5 trillion spent in healthcare. From this $3.5 trillion, the estimated total costs of diagnosed diabetes rose to $327 billion in 2017 from $245 billion in 2012, according to the American Diabetes Association.

On a more individual level, patients with diagnosed diabetes incur an average of about $7,900 per year in medical expenses due to this condition.

With diabetes driving healthcare costs on both a national and individual level, it is vital that a model like CCM identifies resources that can help support healthy lifestyles without financial strain. CCCs recognize high healthcare costs and identify less costly choices with online discounts, pharmacy comparisons and benefit programs. This can substantially help relieve financial stresses for patients with diabetes. It can also drive outcomes like reducing patients’ emergency room visits while increasing in-patient visits.

For example, Wellbox worked with a patient who was paying $900 for their diabetes medication and we were able to provide medication and financial assistance resources. This brought the medication cost down from $900 to $150.

Other resources that CCCs can connect to patients to better manage their diabetes and its complications include assistance programs, support groups, counseling sessions, training, and local community organizations. This type of support can assist in the patients’ self-management of this difficult condition.


CCM is proven to effectively deliver positive outcomes for diabetic patient populations. By implementing the strategies listed above together, this model offers a more comprehensive approach to educating and supporting patients with self-management. In turn, this can lead to greater patient satisfaction, compliance, and healthcare savings.

Interested in learning more about what an experienced CCM provider should successfully do to drive positive outcomes for people living with diabetes? Contact us today to learn more.


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Designed to improve clinical outcomes for diabetic populations, adopting telehealth solutions like Chronic Care Management and Remote Patient Monitoring can benefit both your practice and its patients. Discover how by downloading our latest whitepaper.

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