Welcome to the next section of our CDE Exam Study Guide series. While the previous chapters focused on who to screen and what prevention interventions to use, Chapter 6 shifts the focus to how that care is delivered.
“Organization of Diabetes Care” might sound dry compared to clinical topics, but do not skip this section. The CDE exam tests your understanding of the Chronic Care Model (CCM) because evidence shows that the structure of care is just as important as the medication prescribed.
Why this chapter matters for the CDE Exam:
The guidelines explicitly state that a “proactive, interprofessional team” is superior to standard care. You need to know the specific definitions of strategies like Case Management and Facilitated Relay of Information, as the exam may present a clinical scenario and ask you to identify which Quality Improvement (QI) strategy is being used.
High-Yield Exam Themes:
- The Shift to Proactive Care: Moving from acute, reactive care to planned, population-based care.
- The 6 Components of the CCM: You should be able to identify examples of Delivery System Design vs. Decision Support vs. Clinical Information Systems.
- Telehealth: Know that it is a proven tool for reducing A1C and improving access, particularly when it allows for medication adjustment.
Below is your study guide to mastering the organizational frameworks that underpin effective diabetes management in Canada.
1. Chapter Overview
This chapter addresses the “Care Gap”—the difference between evidence-based goals and actual clinical practice. It argues that to close this gap, we must redesign primary care using the Expanded Chronic Care Model (CCM). The goal is to transform care from “acute and reactive” to “proactive, planned, and population-based”.
2. Key Messages (The "Gold Nuggets")
Patient-Centred: Care must be organized around the person living with diabetes, who is the most important member of the team.
Proactive Team: Care should be facilitated by an interprofessional team that provides ongoing self-management education and support.
The Framework: Care should be delivered using the components of the Chronic Care Model (CCM).
Data-Driven: Structured care must be supported by clinical information systems (registries, reminders, audits).
3. The Chronic Care Model (CCM)
The CCM is the evidence-based framework for this chapter. It includes 6 essential components that work together. For the exam, memorize the examples for each component found in Table 1 in the guidelines.
A. Delivery System Design (How we structure the visit/team)
Team-Based Care: Multidisciplinary team with specific diabetes training.
Case Management: A structured intervention (often by a nurse, pharmacist, or dietitian) involving medication adjustment, monitoring, and care coordination. Note: Case management with medication adjustment has the greatest impact on lowering A1C.
Shared Care: Joint participation of primary care and specialists.
B. Self-Management Support (Empowering the patient)
Activities that support the patient in managing their disease (education, coaching, peer support).
This is the cornerstone of diabetes care in the CCM.
C. Decision Support (Helping the provider make the right choice)
Evidence-Based Guidelines: Embedding guidelines into EMRs.
Audit and Feedback: Summarizing provider performance to increase awareness.
Benchmarking: Comparing performance against a peer group.
D. Clinical Information Systems (The data backbone)
Patient Registries: A list of all patients with diabetes to track care (preventing patients from “falling through the cracks”).
Clinician/Patient Reminders: Prompts to recall patients or perform tasks (e.g., foot exam reminders).
Facilitated Relay of Information: Collection of patient data (e.g., home glucose logs) sent to the clinician, ideally one who can adjust meds.
E. The Community
Building healthy public policy and supportive environments.
F. Health Systems
Leadership and organization of healthcare.
4. Quality Improvement (QI) Strategies
Multi-component is Best: Interventions targeting the system (e.g., team changes + registries + case management) produce the greatest effect.
Effectiveness: The more CCM components used, the better the outcomes.
Rural Areas: Using 3 or more QI strategies significantly increases the impact on self-management compared to using a single strategy.
5. Telehealth
Telehealth is defined as the provision of healthcare remotely (telephone, video, web-based).
Evidence: It is one of the few QI strategies with consistent evidence for improving glycemia and cardiovascular risk factors.
A1C Impact: Improvement is most likely when the system allows for medication adjustment.
Target: A1C improvement is greater when the baseline A1C is higher (>8.0%).
6. Clinical Decision Algorithm
While this chapter is less “algorithmic” than others, visualize the workflow of an Optimized Practice:
Register: Create a patient registry to identify everyone with diabetes.
Recall: Use the registry to generate reminders for overdue labs/visits.
Resource: Assign an interprofessional team (Nurse, Dietitian, Pharmacist) to the patient.
Relay: Establish a system for the patient to send data (glucose data from CGM on CBG) to the team.
Review: Use decision support tools (guidelines, flow sheets) during the visit.
7. Diabetes Canada Clinical Practice Guidelines Recommendations
Key Recommendations to Memorize:
Team Care: Care should be facilitated by a proactive, interprofessional team with specific training in diabetes.
QI Strategies: The following strategies should be used to reduce A1C and improve adherence:
Promotion of self-management.
Team changes.
Case management.
Electronic patient registries.
Facilitated relay of clinical information.
Case Manager Role: The role of the diabetes case manager should be enhanced to include interventions led by a nurse, pharmacist, or dietitian to improve coordination and facilitate timely changes to management.
Telehealth: Telehealth technologies may be used to:
Improve self-management in underserviced communities.
Improve clinical outcomes (A1C, guideline adherence) in Type 2 diabetes.