Introduction

Diabetes mellitus is a chronic lifelong disease whose management requires ongoing collaboration among a team of health care providers and the patient. Although primary care physicians (PCPs) provide the majority of diabetes care, they are unable to meet the ongoing and growing demands of diabetes management by themselves, needing instead to be a part of an amplified care system. The health care system is beginning to evolve from its historic orientation toward acute illnesses, but acute care remains the dominant paradigm. Management of complex chronic illnesses is given insufficient attention, with inadequate time for physician-patient interactions, and with diabetes often treated alongside other chronic conditions. It is unrealistic to expect chronic diseases, such as diabetes, to be managed in a health care system designed for acute conditions.

The growing incidence of diabetes has been a driving force behind this supplement, which explores a variety of health care models that are evolving to manage chronic illness in the United States (US). With an estimated 25.8 million US adults and children (8.3% of the population) diagnosed with diabetes and 79 million people with pre-diabetes,¹ establishment of effective diabetes care approaches is a major health care priority. Many Americans are uninsured or underinsured,¹ placing them at potentially devastating economic risk. Consideration of race or ethnicity is also essential in establishing effective health care approaches in the US, ensuring care addresses the unique cultural needs of American Indians and Alaska Natives (with diabetes prevalence rates varying by region, from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona), non-Hispanic blacks (12.6%), Hispanics (11.8%), Asian Americans (8.4%), and non-Hispanic whites (7.1%).²

The burden of diabetes is personal, societal, and economic. The ability of the health care system to meet treatment goals of the American Diabetes Association³ and the American Association of Clinical Endocrinologists⁴ is grossly inadequate. Approximately 40% of people with diabetes are not achieving glycated hemoglobin targets⁵ and only an astonishingly low 12.2% of treated patients meet the combined targets for glycated hemoglobin, blood pressure, and cholesterol.⁶ The prevalence of macrovascular and microvascular complications that arise due to suboptimal glycemic control is unacceptable. Heart disease mortality and risk of stroke are both 2–4 times higher in people with diabetes than in the general population. Diabetes is the leading cause of blindness among adults, is a principal cause of kidney failure, and accounts for 60% of nontraumatic lower-limb amputations. The societal and economic impact of diabetes and its complications are no less staggering, with $174 billion in estimated total costs as of 2007 ($116 billion in direct medical costs, and $58 billion in indirect costs, such as disability, work loss, and premature mortality). Factoring in the additional costs of undiagnosed diabetes, pre-diabetes, and gestational diabetes brings the total cost of diabetes in the US in 2007 to $218 billion.²

Given the extent of the problem and the cultural and socioeconomic diversity of people living with diabetes, it is clear that there is no one correct diabetes care model that will address these factors. However, core elements have been defined that should be considered in all. The Chronic Care Model (CCM) developed by Ed Wagner is the most widely recognized approach for improving diabetes care at the levels of the community, organization, practice, and patient.⁷ While disease management programs vary in design and implementation, almost all emphasize 1 or more of the 6 core elements of the CCM as a framework for promoting high-quality chronic disease care and improving outcomes.⁸ The CCM rests on the premise that the combination of an informed, active patient, working with providers who have resources and expertise, leads to productive interactions and improved outcomes.⁹ There is substantial evidence that chronic disease management strategies “achieve better disease control, higher patient satisfaction, and better adherence to guidelines by redesigning delivery systems to meet the needs of chronically ill patients.”¹⁰

While the PCP, acting as an individual, can implement each of the 6 elements of the CCM, it is important to see the elements as components of a comprehensive and coordinated approach to care. Research suggests that the more aspects of the CCM you use, the more likely you are to achieve better process and patient outcomes.¹¹ The 6 core elements are:

The community: partnerships with community programs to support patients’ needs.

Health system design: creation of a culture, organization, and mechanisms that promote safe, high-quality care.

Self-management support: recognizing the central role of the patient in managing his or her own care.

Delivery system design: focus on teamwork; proactive vs reactive health care management; follow-up beyond the office visit; case management for more complex patients; recognition of cultural variations.

Decision support: use of evidence-based treatment, with clinician access to ongoing education.

Clinical information systems: data available to monitor progress at the individual patient level and the service level.

In this supplement, several models for the treatment and management of diabetes patients are discussed as alternatives to conventional management in the PCP’s office. Christina R. Bratcher, MD, FACE, and Elizabeth Bello, RD, LD, CDE, describe a centralized multidisciplinary team approach that integrates the skills of practitioners from different disciplines, all practicing under one roof: generalist and specialist physicians, registered nurses and nurse practitioners, physician assistants, certified diabetes educators, dietitians, and, possibly, pharmacists. Patients receive all of their diabetes care in an integrated fashion and in a single stop: medical care, individualized diabetes education, nutrition, exercise and lifestyle coaching, and counseling and monitoring of drug effects. Integration of care is facilitated by the use of electronic medical records. Evidence suggests that this approach results in improved patient outcomes and reduced overall costs. However, the main issue of concern with the model is the negotiation of coverage, which leaves the patient responsible for some noncovered services. The expenses could be substantial and the patient might have to decide which services to receive.

Sweta Chawla, PharmD, MS, CDE, describes a nontraditional model of diabetes care delivered by pharmacists, called medication therapy management (MTM). Pharmacists are playing an increasing role in diabetes management and their rapid growth as a sector of qualified health professionals makes them an important asset that should complement primary diabetes care. The pharmacist can help improve outcomes by preventing medication-related morbidity and mortality and providing patient education. However, it is of concern that a physician referral is not needed for MTM services and that the pharmacist can take over patient care and even override the physician’s recommendations, as suggested in the case presented by Dr. Chawla. The role of pharmacist-delivered MTM in the overall scheme of diabetes management is clear: it can help optimize diabetes drug therapy, reducing risks and possibly also improving patient compliance via educational interventions. However, pharmacist-delivered MTM should definitely be part of an integrated and coordinated multidisciplinary team, whether centralized or not.

The boutique medicine model, developed in the 1990s, has provided physicians hampered by the constraints of managed care with an alternative approach to increasing the amount of time spent with each patient and improving their quality of care. In this model, the practice enrolls fewer patients and each patient pays a monthly or annual fee to have improved access to services. In return, the patient receives extended visits with a comprehensive plan of care that includes not only medical assessment, but also individualized education and close follow-up. In the practice described by Jeffrey P. Schyberg, MD, the physician has time to undertake multiple aspects of diabetes care, including extensive diabetes education. This approach might deny patients the opportunity to utilize valuable available resources and skills from other health care providers that are important for the integral management of diabetes. The business model is attractive; however, the services are not available to most patients. Boutique medicine has raised mixed reactions, but is currently considered part of physicians’ free market opportunities by the American Medical Association.

In the final section, K.C. Arnold, NP, CDE (ANP, BCADM), describes a nontraditional/noncentralized model of diabetes care led by other health care providers—in this case, nurse practitioners (NPs). Advanced-practice nurses are increasingly delivering primary care to fill gaps left by the physician shortage. The American Nurses Credentialing Center has partnered with organizations, including the American Association of Diabetes Educators and the American Diabetes Association, to establish credentialing that allows NPs to fill more specialized diabetes management roles. These roles can be accomplished within physician-led practices, but also in independently run clinics, with or without physician involvement, depending on state laws. The article presents evidence that NP-provided primary care can be comparable to physician care for multiple health outcomes, and it emphasizes the nurturing nature of the patient-provider relationship within this model. The limitations for the NP-led practice described in this article seem to be similar to the ones encountered by traditional physician-led models, with cost and reimbursement issues and a high patient volume requiring follow-up visits to be spaced every 3 months. Nurse-led practices have the additional challenges of legal restrictions and physician resistance.

Another model, which is not discussed in this supplement but shares elements of the CCM, is the Patient-Centered Medical Home (PCMH). This model has been gaining attention and popularity in recent times.¹² The PCMH has been proposed as an enhanced model of primary care,¹³ with the following key components: care coordination, quality and safety, whole person orientation, personal physician, physician leadership, enhanced access, and payment. Within this model, each patient has a personal physician or provider who leads a team to ensure that care is coordinated across different specialties and providers, and health care team meetings take place at regular intervals. Aspects of care for which in-depth medical training is not required may be delegated to nonphysician members of the health care team.¹² Randomized trials have not yet been conducted, but PCMH pilot initiatives across the US have reported encouraging results, which support this model as a useful strategy for improving the quality and costs of diabetes care.¹²

No single model of care has been fully able to overcome the limitations that patients and health care providers encounter in trying to achieve quality diabetes care. The authors of the articles in this supplement have tried to provide the reader with a glimpse of their specific practices, with a candid view of the advantages and disadvantages inherent to their own models. With consideration given to the 6 core components of the Chronic Care Model, we hope that the reader will find elements in these models to stimulate the development of his or her own opinions regarding provision of optimal care for our patients with diabetes.

Diabetes mellitus is a chronic lifelong disease whose management requires ongoing collaboration among a team of health care providers and the patient. Although primary care physicians (PCPs) provide the majority of diabetes care, they are unable to meet the ongoing and growing demands of diabetes management by themselves, needing instead to be a part of an amplified care system. The health care system is beginning to evolve from its historic orientation toward acute illnesses, but acute care remains the dominant paradigm. Management of complex chronic illnesses is given insufficient attention, with inadequate time for physician-patient interactions, and with diabetes often treated alongside other chronic conditions. It is unrealistic to expect chronic diseases, such as diabetes, to be managed in a health care system designed for acute conditions.

The growing incidence of diabetes has been a driving force behind this supplement, which explores a variety of health care models that are evolving to manage chronic illness in the United States (US). With an estimated 25.8 million US adults and children (8.3% of the population) diagnosed with diabetes and 79 million people with pre-diabetes,¹ establishment of effective diabetes care approaches is a major health care priority. Many Americans are uninsured or underinsured,¹ placing them at potentially devastating economic risk. Consideration of race or ethnicity is also essential in establishing effective health care approaches in the US, ensuring care addresses the unique cultural needs of American Indians and Alaska Natives (with diabetes prevalence rates varying by region, from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona), non-Hispanic blacks (12.6%), Hispanics (11.8%), Asian Americans (8.4%), and non-Hispanic whites (7.1%).²

The burden of diabetes is personal, societal, and economic. The ability of the health care system to meet treatment goals of the American Diabetes Association³ and the American Association of Clinical Endocrinologists⁴ is grossly inadequate. Approximately 40% of people with diabetes are not achieving glycated hemoglobin targets⁵ and only an astonishingly low 12.2% of treated patients meet the combined targets for glycated hemoglobin, blood pressure, and cholesterol.⁶ The prevalence of macrovascular and microvascular complications that arise due to suboptimal glycemic control is unacceptable. Heart disease mortality and risk of stroke are both 2–4 times higher in people with diabetes than in the general population. Diabetes is the leading cause of blindness among adults, is a principal cause of kidney failure, and accounts for 60% of nontraumatic lower-limb amputations. The societal and economic impact of diabetes and its complications are no less staggering, with $174 billion in estimated total costs as of 2007 ($116 billion in direct medical costs, and $58 billion in indirect costs, such as disability, work loss, and premature mortality). Factoring in the additional costs of undiagnosed diabetes, pre-diabetes, and gestational diabetes brings the total cost of diabetes in the US in 2007 to $218 billion.²

Given the extent of the problem and the cultural and socioeconomic diversity of people living with diabetes, it is clear that there is no one correct diabetes care model that will address these factors. However, core elements have been defined that should be considered in all. The Chronic Care Model (CCM) developed by Ed Wagner is the most widely recognized approach for improving diabetes care at the levels of the community, organization, practice, and patient.⁷ While disease management programs vary in design and implementation, almost all emphasize 1 or more of the 6 core elements of the CCM as a framework for promoting high-quality chronic disease care and improving outcomes.⁸ The CCM rests on the premise that the combination of an informed, active patient, working with providers who have resources and expertise, leads to productive interactions and improved outcomes.⁹ There is substantial evidence that chronic disease management strategies “achieve better disease control, higher patient satisfaction, and better adherence to guidelines by redesigning delivery systems to meet the needs of chronically ill patients.”¹⁰

While the PCP, acting as an individual, can implement each of the 6 elements of the CCM, it is important to see the elements as components of a comprehensive and coordinated approach to care. Research suggests that the more aspects of the CCM you use, the more likely you are to achieve better process and patient outcomes.¹¹ The 6 core elements are:

The community: partnerships with community programs to support patients’ needs.

Health system design: creation of a culture, organization, and mechanisms that promote safe, high-quality care.

Self-management support: recognizing the central role of the patient in managing his or her own care.

Delivery system design: focus on teamwork; proactive vs reactive health care management; follow-up beyond the office visit; case management for more complex patients; recognition of cultural variations.

Decision support: use of evidence-based treatment, with clinician access to ongoing education.

Clinical information systems: data available to monitor progress at the individual patient level and the service level.

In this supplement, several models for the treatment and management of diabetes patients are discussed as alternatives to conventional management in the PCP’s office. Christina R. Bratcher, MD, FACE, and Elizabeth Bello, RD, LD, CDE, describe a centralized multidisciplinary team approach that integrates the skills of practitioners from different disciplines, all practicing under one roof: generalist and specialist physicians, registered nurses and nurse practitioners, physician assistants, certified diabetes educators, dietitians, and, possibly, pharmacists. Patients receive all of their diabetes care in an integrated fashion and in a single stop: medical care, individualized diabetes education, nutrition, exercise and lifestyle coaching, and counseling and monitoring of drug effects. Integration of care is facilitated by the use of electronic medical records. Evidence suggests that this approach results in improved patient outcomes and reduced overall costs. However, the main issue of concern with the model is the negotiation of coverage, which leaves the patient responsible for some noncovered services. The expenses could be substantial and the patient might have to decide which services to receive.

Sweta Chawla, PharmD, MS, CDE, describes a nontraditional model of diabetes care delivered by pharmacists, called medication therapy management (MTM). Pharmacists are playing an increasing role in diabetes management and their rapid growth as a sector of qualified health professionals makes them an important asset that should complement primary diabetes care. The pharmacist can help improve outcomes by preventing medication-related morbidity and mortality and providing patient education. However, it is of concern that a physician referral is not needed for MTM services and that the pharmacist can take over patient care and even override the physician’s recommendations, as suggested in the case presented by Dr. Chawla. The role of pharmacist-delivered MTM in the overall scheme of diabetes management is clear: it can help optimize diabetes drug therapy, reducing risks and possibly also improving patient compliance via educational interventions. However, pharmacist-delivered MTM should definitely be part of an integrated and coordinated multidisciplinary team, whether centralized or not.

The boutique medicine model, developed in the 1990s, has provided physicians hampered by the constraints of managed care with an alternative approach to increasing the amount of time spent with each patient and improving their quality of care. In this model, the practice enrolls fewer patients and each patient pays a monthly or annual fee to have improved access to services. In return, the patient receives extended visits with a comprehensive plan of care that includes not only medical assessment, but also individualized education and close follow-up. In the practice described by Jeffrey P. Schyberg, MD, the physician has time to undertake multiple aspects of diabetes care, including extensive diabetes education. This approach might deny patients the opportunity to utilize valuable available resources and skills from other health care providers that are important for the integral management of diabetes. The business model is attractive; however, the services are not available to most patients. Boutique medicine has raised mixed reactions, but is currently considered part of physicians’ free market opportunities by the American Medical Association.

In the final section, K.C. Arnold, NP, CDE (ANP, BCADM), describes a nontraditional/noncentralized model of diabetes care led by other health care providers—in this case, nurse practitioners (NPs). Advanced-practice nurses are increasingly delivering primary care to fill gaps left by the physician shortage. The American Nurses Credentialing Center has partnered with organizations, including the American Association of Diabetes Educators and the American Diabetes Association, to establish credentialing that allows NPs to fill more specialized diabetes management roles. These roles can be accomplished within physician-led practices, but also in independently run clinics, with or without physician involvement, depending on state laws. The article presents evidence that NP-provided primary care can be comparable to physician care for multiple health outcomes, and it emphasizes the nurturing nature of the patient-provider relationship within this model. The limitations for the NP-led practice described in this article seem to be similar to the ones encountered by traditional physician-led models, with cost and reimbursement issues and a high patient volume requiring follow-up visits to be spaced every 3 months. Nurse-led practices have the additional challenges of legal restrictions and physician resistance.

Another model, which is not discussed in this supplement but shares elements of the CCM, is the Patient-Centered Medical Home (PCMH). This model has been gaining attention and popularity in recent times.¹² The PCMH has been proposed as an enhanced model of primary care,¹³ with the following key components: care coordination, quality and safety, whole person orientation, personal physician, physician leadership, enhanced access, and payment. Within this model, each patient has a personal physician or provider who leads a team to ensure that care is coordinated across different specialties and providers, and health care team meetings take place at regular intervals. Aspects of care for which in-depth medical training is not required may be delegated to nonphysician members of the health care team.¹² Randomized trials have not yet been conducted, but PCMH pilot initiatives across the US have reported encouraging results, which support this model as a useful strategy for improving the quality and costs of diabetes care.¹²

No single model of care has been fully able to overcome the limitations that patients and health care providers encounter in trying to achieve quality diabetes care. The authors of the articles in this supplement have tried to provide the reader with a glimpse of their specific practices, with a candid view of the advantages and disadvantages inherent to their own models. With consideration given to the 6 core components of the Chronic Care Model, we hope that the reader will find elements in these models to stimulate the development of his or her own opinions regarding provision of optimal care for our patients with diabetes.

Diabetes mellitus is a chronic lifelong disease whose management requires ongoing collaboration among a team of health care providers and the patient. Although primary care physicians (PCPs) provide the majority of diabetes care, they are unable to meet the ongoing and growing demands of diabetes management by themselves, needing instead to be a part of an amplified care system. The health care system is beginning to evolve from its historic orientation toward acute illnesses, but acute care remains the dominant paradigm. Management of complex chronic illnesses is given insufficient attention, with inadequate time for physician-patient interactions, and with diabetes often treated alongside other chronic conditions. It is unrealistic to expect chronic diseases, such as diabetes, to be managed in a health care system designed for acute conditions.

The growing incidence of diabetes has been a driving force behind this supplement, which explores a variety of health care models that are evolving to manage chronic illness in the United States (US). With an estimated 25.8 million US adults and children (8.3% of the population) diagnosed with diabetes and 79 million people with pre-diabetes,¹ establishment of effective diabetes care approaches is a major health care priority. Many Americans are uninsured or underinsured,¹ placing them at potentially devastating economic risk. Consideration of race or ethnicity is also essential in establishing effective health care approaches in the US, ensuring care addresses the unique cultural needs of American Indians and Alaska Natives (with diabetes prevalence rates varying by region, from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona), non-Hispanic blacks (12.6%), Hispanics (11.8%), Asian Americans (8.4%), and non-Hispanic whites (7.1%).²

The burden of diabetes is personal, societal, and economic. The ability of the health care system to meet treatment goals of the American Diabetes Association³ and the American Association of Clinical Endocrinologists⁴ is grossly inadequate. Approximately 40% of people with diabetes are not achieving glycated hemoglobin targets⁵ and only an astonishingly low 12.2% of treated patients meet the combined targets for glycated hemoglobin, blood pressure, and cholesterol.⁶ The prevalence of macrovascular and microvascular complications that arise due to suboptimal glycemic control is unacceptable. Heart disease mortality and risk of stroke are both 2–4 times higher in people with diabetes than in the general population. Diabetes is the leading cause of blindness among adults, is a principal cause of kidney failure, and accounts for 60% of nontraumatic lower-limb amputations. The societal and economic impact of diabetes and its complications are no less staggering, with $174 billion in estimated total costs as of 2007 ($116 billion in direct medical costs, and $58 billion in indirect costs, such as disability, work loss, and premature mortality). Factoring in the additional costs of undiagnosed diabetes, pre-diabetes, and gestational diabetes brings the total cost of diabetes in the US in 2007 to $218 billion.²

Given the extent of the problem and the cultural and socioeconomic diversity of people living with diabetes, it is clear that there is no one correct diabetes care model that will address these factors. However, core elements have been defined that should be considered in all. The Chronic Care Model (CCM) developed by Ed Wagner is the most widely recognized approach for improving diabetes care at the levels of the community, organization, practice, and patient.⁷ While disease management programs vary in design and implementation, almost all emphasize 1 or more of the 6 core elements of the CCM as a framework for promoting high-quality chronic disease care and improving outcomes.⁸ The CCM rests on the premise that the combination of an informed, active patient, working with providers who have resources and expertise, leads to productive interactions and improved outcomes.⁹ There is substantial evidence that chronic disease management strategies “achieve better disease control, higher patient satisfaction, and better adherence to guidelines by redesigning delivery systems to meet the needs of chronically ill patients.”¹⁰

While the PCP, acting as an individual, can implement each of the 6 elements of the CCM, it is important to see the elements as components of a comprehensive and coordinated approach to care. Research suggests that the more aspects of the CCM you use, the more likely you are to achieve better process and patient outcomes.¹¹ The 6 core elements are:

The community: partnerships with community programs to support patients’ needs.

Health system design: creation of a culture, organization, and mechanisms that promote safe, high-quality care.

Self-management support: recognizing the central role of the patient in managing his or her own care.

Delivery system design: focus on teamwork; proactive vs reactive health care management; follow-up beyond the office visit; case management for more complex patients; recognition of cultural variations.

Decision support: use of evidence-based treatment, with clinician access to ongoing education.

Clinical information systems: data available to monitor progress at the individual patient level and the service level.

In this supplement, several models for the treatment and management of diabetes patients are discussed as alternatives to conventional management in the PCP’s office. Christina R. Bratcher, MD, FACE, and Elizabeth Bello, RD, LD, CDE, describe a centralized multidisciplinary team approach that integrates the skills of practitioners from different disciplines, all practicing under one roof: generalist and specialist physicians, registered nurses and nurse practitioners, physician assistants, certified diabetes educators, dietitians, and, possibly, pharmacists. Patients receive all of their diabetes care in an integrated fashion and in a single stop: medical care, individualized diabetes education, nutrition, exercise and lifestyle coaching, and counseling and monitoring of drug effects. Integration of care is facilitated by the use of electronic medical records. Evidence suggests that this approach results in improved patient outcomes and reduced overall costs. However, the main issue of concern with the model is the negotiation of coverage, which leaves the patient responsible for some noncovered services. The expenses could be substantial and the patient might have to decide which services to receive.

Sweta Chawla, PharmD, MS, CDE, describes a nontraditional model of diabetes care delivered by pharmacists, called medication therapy management (MTM). Pharmacists are playing an increasing role in diabetes management and their rapid growth as a sector of qualified health professionals makes them an important asset that should complement primary diabetes care. The pharmacist can help improve outcomes by preventing medication-related morbidity and mortality and providing patient education. However, it is of concern that a physician referral is not needed for MTM services and that the pharmacist can take over patient care and even override the physician’s recommendations, as suggested in the case presented by Dr. Chawla. The role of pharmacist-delivered MTM in the overall scheme of diabetes management is clear: it can help optimize diabetes drug therapy, reducing risks and possibly also improving patient compliance via educational interventions. However, pharmacist-delivered MTM should definitely be part of an integrated and coordinated multidisciplinary team, whether centralized or not.

The boutique medicine model, developed in the 1990s, has provided physicians hampered by the constraints of managed care with an alternative approach to increasing the amount of time spent with each patient and improving their quality of care. In this model, the practice enrolls fewer patients and each patient pays a monthly or annual fee to have improved access to services. In return, the patient receives extended visits with a comprehensive plan of care that includes not only medical assessment, but also individualized education and close follow-up. In the practice described by Jeffrey P. Schyberg, MD, the physician has time to undertake multiple aspects of diabetes care, including extensive diabetes education. This approach might deny patients the opportunity to utilize valuable available resources and skills from other health care providers that are important for the integral management of diabetes. The business model is attractive; however, the services are not available to most patients. Boutique medicine has raised mixed reactions, but is currently considered part of physicians’ free market opportunities by the American Medical Association.

In the final section, K.C. Arnold, NP, CDE (ANP, BCADM), describes a nontraditional/noncentralized model of diabetes care led by other health care providers—in this case, nurse practitioners (NPs). Advanced-practice nurses are increasingly delivering primary care to fill gaps left by the physician shortage. The American Nurses Credentialing Center has partnered with organizations, including the American Association of Diabetes Educators and the American Diabetes Association, to establish credentialing that allows NPs to fill more specialized diabetes management roles. These roles can be accomplished within physician-led practices, but also in independently run clinics, with or without physician involvement, depending on state laws. The article presents evidence that NP-provided primary care can be comparable to physician care for multiple health outcomes, and it emphasizes the nurturing nature of the patient-provider relationship within this model. The limitations for the NP-led practice described in this article seem to be similar to the ones encountered by traditional physician-led models, with cost and reimbursement issues and a high patient volume requiring follow-up visits to be spaced every 3 months. Nurse-led practices have the additional challenges of legal restrictions and physician resistance.

Another model, which is not discussed in this supplement but shares elements of the CCM, is the Patient-Centered Medical Home (PCMH). This model has been gaining attention and popularity in recent times.¹² The PCMH has been proposed as an enhanced model of primary care,¹³ with the following key components: care coordination, quality and safety, whole person orientation, personal physician, physician leadership, enhanced access, and payment. Within this model, each patient has a personal physician or provider who leads a team to ensure that care is coordinated across different specialties and providers, and health care team meetings take place at regular intervals. Aspects of care for which in-depth medical training is not required may be delegated to nonphysician members of the health care team.¹² Randomized trials have not yet been conducted, but PCMH pilot initiatives across the US have reported encouraging results, which support this model as a useful strategy for improving the quality and costs of diabetes care.¹²

No single model of care has been fully able to overcome the limitations that patients and health care providers encounter in trying to achieve quality diabetes care. The authors of the articles in this supplement have tried to provide the reader with a glimpse of their specific practices, with a candid view of the advantages and disadvantages inherent to their own models. With consideration given to the 6 core components of the Chronic Care Model, we hope that the reader will find elements in these models to stimulate the development of his or her own opinions regarding provision of optimal care for our patients with diabetes.