Toolkit Overview

The resources in this Clinical Toolkit can assist primary care teams in streamlining processes and improving care related to diabetes health, with a primary focus on controlling A1C and eliminating disparities in A1C control.

This toolkit was adapted from prior successful statewide efforts to improve glycemic control and may be used by participating clinical practice sites to aid in the development of rapid Plan-Do-Study-Act (PDSA) cycles to test interventions designed to impact the key drivers of A1C control.

Chronic Care Model

The Key Driver Diagram and interventions were informed by evidence from referenced studies and are based on a modified version of the expanded Chronic Care Model that has been used successfully to improve patient outcomes for adults with diabetes as well as prevention.⁷ Controlling diabetes effectively requires a focus on multiple layers. For instance, medications must be started and increased appropriately by providers. Patients need to become engaged in improving behaviors such as medication taking, appointment keeping, and healthy lifestyle.^8-10

In addition, payors, communities, and health care systems need to systematically support healthy environments of care, peer and social support, modify policies to improve care, and support disease management between patients and their practice team. There is growing evidence that linkages to community resources for health improvement can improve health outcomes.^11-13 

View Key Driver Diagram Download Toolkit 

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