A diabetes care delivery model in which registered nurses (RNs) facilitate proactive, evidence-based care through direct engagement with patients, clinicians, pharmacists, and other team members successfully increased the number of patients meeting key diabetes management metrics, according to a review published in the Annals of Family Medicine.

A total of 7215 diabetes patients aged 18 to 75 years participated in the initiative, known as the Enhanced Care Team RN Process. These patients were cared for by 318 primary care clinicians (PCCs), 90 care team RNs, and 6 pharmacists.

The Enhanced Care Team RN Process was piloted in 1 clinic for 14 months before it was rolled out to 4 additional clinics over a 3-month period. In advance of the rollout, RNs attended a 4 hour education session and studied an electronic health record (EHR) documentation guide. Every participating RN was paired with a PCC, and the providers met monthly to discuss progress and challenges.

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Nurses were responsible for identifying patients who did not meet the composite D5 diabetes quality indicator which includes glycemic and blood pressure control, non-smoking status, aspirin use, and statin use. After reviewing the patient’s current management plan, each RN was guided by a process algorithm to engage the clinical pharmacist for treatment recommendations, a social worker for addressing social determinants of health, and, if necessary, an appointment coordinator.

Subsequently, the RN would communicate with the PCC to finalize the care plan and work with the patient to tailor the plan to fit their needs. After facilitating the implementation of the care plan, the RN followed longitudinally until all D5 metrics were met.

The goal of the Enhanced Care Team RN Process was to review 10% of patients not meeting D5 criteria each month. The team well exceeded this goal; within 6 months of the process’ implementation, 26.9% (n=1940) of eligible patients were enrolled, and 28.1% (n=546) of these patients converted to meeting all D5 metrics. As a result, the composite D5 metric increased from 39.3% to 43.1% of eligible patients.

The group of clinicians who developed the Enhanced Care Team RN Process is currently soliciting feedback to optimize the process and reviewing provider input.

“RNs appreciated increased engagement and responsibility, but not the complexity of the intervention and added workload,” the authors said. “Most PCCs welcomed the RN role, while advocating for process improvements to support team members and flexibility of care in response to patient goals/situation.”


Herges JR, Ruehmann LL, Matulis JC, Hickox BC, McCoy RG. Enhanced care team nurse process to improve diabetes care. Ann Fam Med. 2020;18(5):463.