Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice

Diabetes Educ. Mar-Apr 2005;31(2):225-34. doi: 10.1177/0145721705275325.


Purpose: The purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on providers' diabetes care practices and patient outcomes in a rural practice setting.

Methods: In this pilot study, 104 patients with type 2 diabetes and 6 providers in a rural primary care practice were involved in an intervention that included a certified diabetes educator (CDE) who educated and supported providers on diabetes management and adherence to the American Diabetes Association (ADA) Standards of Care over the year of the project. The CDE also provided diabetes self-management education (DSME) at the office site for 29 of the 104 patients who received their care in the practice. The following variables were evaluated: provider perceived barriers to care and adherence to ADA standards of care and patient A1C, blood pressure, cholesterol, knowledge, and empowerment levels.

Results: Provider adherence to ADA Standards of Care increased significantly across all process measures. Patients who received DSME at point of service in the primary care practice setting gained improvements in knowledge, empowerment, A1C, and high-density lipoprotein cholesterol levels.

Conclusions: Implementing systems to support decision support, self-management education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

Publication types

  • Evaluation Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Chronic Disease
  • Diabetes Mellitus, Type 2 / metabolism
  • Diabetes Mellitus, Type 2 / prevention & control*
  • Diabetes Mellitus, Type 2 / psychology
  • Educational Measurement
  • Family Practice / organization & administration*
  • Female
  • Glycated Hemoglobin A / metabolism
  • Guideline Adherence / standards
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Male
  • Middle Aged
  • Models, Organizational*
  • Outcome Assessment, Health Care
  • Patient Education as Topic / organization & administration*
  • Pennsylvania
  • Pilot Projects
  • Practice Guidelines as Topic
  • Primary Health Care / organization & administration*
  • Program Development
  • Program Evaluation
  • Rural Health Services / organization & administration*
  • Total Quality Management / organization & administration


  • Glycated Hemoglobin A