Primary care nurse-physician teams were introduced to lead new diabetes health networks, with the aim of connecting providers across sectors and strengthening primary care gatekeeping; collaboration with stakeholders in the early design stages of the initiative encouraged multistakeholder buy-in from the outset; updated evidence-based care pathways published in a guidebook helped streamline and standardize care; extensive patient education and coaching on self-management skills enabled patients to engage in their own care; pragmatic intermediary solutions were found to address pressing challenges; for example, implementing paper medical records carried by the patient to counter poor communication between providers in the absence of an electronic information system.
