1. Team/Organization Name Background and structure Location Brief system information (type, size) Pilot population

2. Aims Statement

3. Measures

5. Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Resources and Policies Community Organization of Health Care Registry Care remind- ers Patient Subgroups Care planning Team roles and tasks Planned visits Continuity Follow-up Guidelines Specialty interaction Provider education Guidelines for patients Emphasize Patient Role Assessment Interventions Care planning and problem solving

6. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Goals Benefits Provider incentives Improvement strategy Senior leaders Health System Resources and Policies Community Organization of Health Care Effective programs Partnerships Coordination

7. Describe Key Changes made. For example: Assessment of selected clinical priorities Evidence-based interventions targeted based on assessment Protocols used Collaborative plan formulated with each participant, based on PCP input and participants readiness Self-management support was emphasized Proactive follow-up for one year Informed, Activated Patient Productive Interactions Prepared Practice Team

8. Functional and Clinical Outcomes List results achieved toward targeted measures Actual Target –HbA1c < 8.0 65% 60% –Self-management goals 25% 50%

9. Strategy for Spread Brief description of your spread approach, including population, site and/or different diseases

10. Barriers Describe challenges here

11. Keys to Success This is a place to summarize the lessons you learned