Table 1 Population care practices surveyed.

Health System Organization

   Financial Incentives

Amount of physician salary at risk, subject to assessment of performance on population care quality indicators.

   Provider Feedback

Reports to providers about performance and degree of blinding to all providers.

Self-Management Support

   Patient Action Plans

Individual goal setting supported by action plans including needs assessment, personalization, and regular clinician review.

   Patient Education

Education and support services based on self-management principles in a variety of formats.

Delivery System Design

   Defined Care Path

An explicit protocol or model guides population care.

   Risk Stratification

Use of an algorithm to stratify patients by risk level and determine the level of proactive care provided.

   Outreach/Follow-Up

Proactive, planned care.

   Inreach

Customized reminders for patients of needed care whenever they present for service.

   Care Coordination

Processes and structures supporting effective patient care handoffs, including explicit protocols and accountabilities.

   Cultural Competence

Care tailored to the needs of major racial, ethnic, and cultural groups.

   Team Accountability

Accountability for patient care vested in care teams rather than individuals.

Decision Support

   Guideline Distribution and Training

Distribution of evidence-based guidelines and clinician training on guideline content, including electronic availability, continuing medical education, and inter-provider communications.

   Provider Alerts

Customized, context-sensitive paper-based or electronic alerts reminding providers of appropriate care for individual patients and groups of patients.

Clinical Information Systems

   Registry

Completeness and quality of a registry or database of key indicators for all patients with diabetes.

   Electronic Medical Record

Availability and comprehensiveness of clinical data during patient visits.