Measuring the Implementation and Effects of a Coordinated Care Model Featuring Diabetes Self-management Education Within Four Patient-Centered Medical Homes

Diabetes Educ. 2015 Jun;41(3):328-42. doi: 10.1177/0145721715577638. Epub 2015 Mar 23.


Purpose: The purpose of this study is to measure the implementation and effects of a multisite coordinated care approach that delivered diabetes self-management education (DSME) and diabetes self-management support (DSMS) for disadvantaged patients within 4 patient-centered medical homes (PCMH).

Methods: A total of 173 patients (69.9% African American, 26.0% Caucasian, and 4.1% other) experienced elements of the intervention, which featured DSME and coordinated care. Key informant interviews with PCMH site staff were used to capture, code, and characterize activities related to implementation and sustainability of the intervention. Outcome measures collected at baseline and at 6 months included clinical health indicators, A1C, body mass index (BMI), blood pressure, and lipids, as well as the AADE7 Behaviors.

Results: A statistically significant decrease occurred in A1C and BMI within 6 months for participants within 1 PCMH. This improvement among clinical health outcomes was associated with the frequency of services provided (eg, DSME, patient support).

Conclusion: Integrating and delivering DSME and DSMS within coordinated care settings have the potential to improve PCMH practice and associated clinical health outcomes for populations experiencing health disparities.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Blood Pressure
  • Body Mass Index
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / psychology*
  • Female
  • Florida
  • Glycated Hemoglobin A / analysis
  • Health Plan Implementation / statistics & numerical data*
  • Health Status Indicators
  • Humans
  • Male
  • Middle Aged
  • Ohio
  • Oklahoma
  • Patient Education as Topic / methods*
  • Patient-Centered Care
  • Program Evaluation / statistics & numerical data*
  • Self Care / methods*
  • Self Care / psychology
  • Tennessee


  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human