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 improving A1C control and addressing health disparities.

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.⁴ 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.^5-7 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.^8-10

High-Impact, High-Reliability Interventions 

Reliability principles help practices design processes that reduce the chance of errors and make it easier for care teams to consistently deliver high-quality care. According to the Institute for Healthcare Improvement (IHI) in its white paper "Improving the Reliability of Health Care," reliability is defined as the ability of a process or system to consistently produce intended results over time.¹¹ This is achieved by reducing reliance on memory and individual vigilance, and instead, designing systems that support consistent performance. 

Appendix 1 (Toolkit Resource 1. Reliability Principles) includes a figure illustrating the progression from low- to high-reliability interventions and demonstrates how system-based approaches are more likely to produce consistent, sustainable improvements than interventions that rely primarily on individual effort. 

High-reliability approaches include building standardized workflows, providing decision support, and implementing system-level processes that improve consistency and lead to better patient outcomes. As you implement the interventions in this toolkit, consider how reliability principles can improve each step of your workflow by reducing variation, minimizing missed opportunities, and making it easier for your team to take the desired actions. 

Based on lessons learned from more than 40 primary care practices participating in Wave 1 and Wave 2 of the AHEAD Initiative, we identified the high-impact, high-reliability interventions included in our Key Driver Diagram. "High-impact" refers to interventions that, when used together as a bundle, have led to improved glycemic control at our sites. Throughout this toolkit, callout boxes highlight practical, tested strategies that primary care teams successfully implemented to improve diabetes care. 

View Key Driver Diagram Download Toolkit 

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