Impact of a Team-Based Chronic Care Model on Clinical Outcomes and Healthcare Utilization in Patients with Type 2 Diabetes in Family Medicine

Abstract

Background: The management of chronic conditions like type 2 diabetes often requires a comprehensive, team-based approach to care. The Chronic Care Model (CCM) provides a framework for implementing this type of approach, but more evidence is needed on its impact in family medicine settings.
Objective: To evaluate the impact of a team-based CCM intervention on clinical outcomes and healthcare utilization in patients with type 2 diabetes in a family medicine practice.
Methods: This was a retrospective, observational study conducted in a family medicine clinic. Patients with type 2 diabetes were included if they received care under the team-based CCM intervention for at least 12 months. Clinical outcomes (HbA1c, blood pressure, lipid profile) and healthcare utilization (emergency department visits, hospitalizations) were compared before and after the implementation of the CCM intervention.
Results: A total of 312 patients with type 2 diabetes were included in the analysis. After the implementation of the team-based CCM intervention, there were significant improvements in HbA1c (-0.5%, p<0.001), systolic blood pressure (-3.2 mmHg, p=0.001), and LDL cholesterol (-7.1 mg/dL, p<0.001). Additionally, the rates of emergency department visits (-27%, p=0.002) and hospitalizations (-34%, p<0.001) were significantly reduced.
Conclusions: The implementation of a team-based Chronic Care Model in a family medicine setting was associated with improved clinical outcomes and reduced healthcare utilization in patients with type 2 diabetes. These findings suggest that the CCM may be an effective approach for managing chronic conditions in the primary care setting.