Practices in the Spotlight

The care of individuals with diabetes—in particular, those with diabetes mellitus (type 2 diabetes)—provides one of the best opportunities to illustrate the promise of the patient centered medical home. The medical home offers patients a team-based model of care led by a provider that ensures high-quality, compassionate and coordinated care, superb access and communication, and is committed to quality and safety. A number of demonstrations and pilot programs across the nation have shown that, properly deployed, the medical home model can improve outcomes and lower costs.

The management of diabetes in the medical home model has been strongly influenced by the Chronic Care Model, a framework has been shown to yield better overall health in the treatment of chronic disease and lower long-term costs. Successful diabetes programs have included elements of the medical home; even if the term itself has not been used, meaningful partnerships have been built between individual patients, their families and their personal physicians. The evidence demonstrates that proper management of diabetes can reduce the risk of complications; well-designed care coordination interventions, delivered to the right individuals, can improve patient, provider and payer outcomes. This guide includes a number of cases studies and exemplary models of diabetes management.