Beyond evidence-based guidelines to implementation: a model for integrating care for people with diabetes

There is a growing realization in the health system that integration of effort may be the best way of ensuring optimal outcomes of management both for clinicians and for people using the health system. It is also hypothesized that the impact of diabetes (chronic disease) and its sequelae could be reduced by the provision of well-organized care, based on agreed evidence-based guidelines for best practice, incorporating patient education and early detection of complication. This paper defines the characteristics of an integrated model of providing care to people with diabetes.