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Care Coordination of Older Adults With Diabetes: A Scoping Review

Open AccessPublished:November 17, 2022DOI:https://doi.org/10.1016/j.jcjd.2022.11.004

      Abstract

      Objectives

      Care coordination is a common intervention to support older adults with diabetes and their caregivers, and provides individualized, integrated health and social care. However, the optimal approach of care coordination is not well described. In this scoping review we synthesized evidence regarding the implementation of traditional and virtual care coordination for older adults with diabetes to inform future research and best practices.

      Methods

      The Joanna Briggs Institute scoping review methods were used. A systematic search was conducted in CINAHL, Embase, EmCare and Medline, as well as a targeted grey literature search, and a hand-search of reference lists. Screening and data extraction were completed by 3 independent reviewers.

      Results

      Forty-two articles were included in the synthesis. Included studies operationalized care coordination in different ways. The most commonly implemented elements of care coordination were regular communication and monitoring. In contrast, coordination between health-care teams and the community, individualized planning and caregiver involvement was less often reported. Outcomes to evaluate the impact of care coordination were predominantly diabetes-centric, and less often person-centred. In addition, evidence indicates that older adults value a trusting and relationship with their care coordinator.

      Conclusions

      Studies assessing care coordination for older adults with diabetes have shown positive outcomes. To inform best practices, future intervention research for this population should focus on evaluating the impact of comprehensive care planning, system navigation across the health and social care sectors, the care coordinator and patient relationship and caregiver support.

      Résumé

      Objectifs

      La coordination des soins est une intervention courante pour soutenir les personnes âgées diabétiques et leurs proches aidants, et permet d’offrir des soins individualisés, intégrés et sociaux. Toutefois, l’approche optimale de la coordination des soins n’est pas bien décrite. Dans la présente étude de portée, nous avons fait la synthèse des données probantes concernant la mise en œuvre de la coordination des soins traditionnels et virtuels offerts aux personnes âgées diabétiques pour orienter les futures recherches et établir des pratiques exemplaires.

      Méthodes

      Nous avons utilisé la méthodologie de l’étude de portée du Joanna Briggs Institute. Nous avons mené une recherche systématique dans CINAHL, Embase, EmCare et Medline, une recherche ciblée de littérature grise et une recherche manuelle dans les listes de références. Trois examinateurs indépendants ont effectué la sélection et l’extraction des données.

      Résultats

      Nous avons inclus 42 articles à la synthèse. Ces études ont contribué à concrétiser la coordination des soins de différentes façons. Les éléments de la coordination des soins les plus fréquemment mis en œuvre étaient la communication et la surveillance régulières. En revanche, la coordination entre les équipes de soins et la communauté, la planification individualisée et la participation des proches aidants était moins souvent signalée. Les résultats pour évaluer les répercussions de la coordination des soins étaient principalement axés sur le diabète et moins souvent axés sur la personne. De plus, les données probantes montrent que les personnes âgées accordent de l’importance à la relation de confiance avec leur coordonnateur de soins.

      Conclusions

      Les études qui évaluaient la coordination des soins offerts aux personnes âgées diabétiques ont démontré des résultats positifs. Pour établir des pratiques exemplaires, les futures recherches en matière d’intervention auprès de cette population devraient porter sur l’évaluation des répercussions de la planification globale des soins, l’orientation dans tous les secteurs du système de santé et de services sociaux, la relation entre le coordonnateur de soins et le patient, et le soutien aux proches aidants.

      Keywords

      Mots clés

      • Care coordination has been implemented in diverse ways, and most commonly focusses on communication and monitoring within and between health-care teams.
      • Outcome measures of care coordination emphasize biometric patient-level outcomes as opposed to overall quality of care, or integrated health and social care.
      • Future research should explore patient and provider preferences and emphasize comprehensive needs assessment in traditional and virtual delivery systems.

      Introduction

      Diabetes is a highly prevalent chronic condition in older adults, affecting more than 25% of those over 65 years of age (
      American Diabetes Association
      12. Older adults: Standards of medical care in diabetes---2021.
      ). The majority of older adults with diabetes are living with other chronic conditions (
      • Gruneir A.
      • Markle-Reid M.
      • Fisher K.
      • Reimer H.
      • Ma X.
      • Ploeg J.
      Comorbidity burden and health services use in community-living older adults with diabetes mellitus: A retrospective cohort study.
      ). Older adults with diabetes may also have geriatric syndromes and multifactorial conditions, such as urinary incontinence and cognitive impairment (
      • Leung E.
      • Wongrakpanich S.
      • Munshi M.N.
      Diabetes management in the elderly.
      ). Furthermore, they may depend on the support of family or friend caregivers who facilitate diabetes-related self-care activities (
      • Ploeg J.
      • Matthew-Maich N.
      • Fraser K.
      • et al.
      Managing multiple chronic conditions in the community: A Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers.
      ). Thus, older adults living with diabetes require a different approach to their care than younger adults (
      • Meneilly G.S.
      • Knip A.
      • Miller D.B.
      • Sherifali D.
      • Tessier D.
      • Zahedi A.
      Diabetes in older people.
      ). Care should be individualized to the older adult’s functional status, coexisting chronic conditions and life expectancy, and patient-centred care planning needs to follow a comprehensive geriatric assessment (
      • Sinclair A.J.
      • Abdelhafiz A.H.
      • Forbes A.
      • Munshi M.
      Evidence-based diabetes care for older people with Type 2 diabetes: A critical review.
      ).
      Care coordination has been used as an intervention to support older adults with complex chronic conditions as they receive care from both the health-care system (e.g. primary care, home care and medical specialists) and social-care programs (e.g. transportation, meal delivery, social programs), but these sectors are not well integrated (
      • Craig C.
      • Eby D.
      • Whittington J.
      Care coordination model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series (white paper).
      ,
      • Singer S.J.
      • Burgers J.
      • Friedberg M.
      • Rosenthal M.B.
      • Leape L.
      • Schneider E.
      Defining and measuring integrated patient care: Promoting the next frontier in health care delivery.
      ,
      • Rich E.
      • Lipson D.
      • Libersky J.
      • Parchman M.
      Coordinating care for adults with complex care needs in the patient-centred medical home: Challenges and solutions (white paper).
      ,
      • Karam M.
      • Chouinard M.C.
      • Poitras M.E.
      • et al.
      Nursing care coordination for patients with complex needs in primary healthcare: A scoping review.
      ,
      • Wodchis W.P.
      • Dixon A.
      • Anderson G.M.
      • Goodwin N.
      Integrating care for older people with complex needs: Key insights and lessons from a seven-country cross-case analysis.
      ,
      • Grembowski D.
      • Shaefer J.
      • Johnson K.E.
      • et al.
      A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.
      ,
      • Bhattacharyya O.
      • Shaw J.
      • Sinha S.
      • et al.
      Innovative integrated health and social care programs in eleven high-income countries.
      ). A coordinated, interprofessional, community-based approach is considered ideal to ensure the physical, mental and social care needs of older adults with diabetes are met (
      • Meneilly G.S.
      • Knip A.
      • Miller D.B.
      • Sherifali D.
      • Tessier D.
      • Zahedi A.
      Diabetes in older people.
      ,
      Diabetes Canada
      Diabetes 360: A Framework for a Diabetes Strategy for Canada.
      ,
      • Clement M.
      • Filteau P.
      • Harvey B.
      • et al.
      Organization of diabetes care.
      ). Care coordination provides “individualized, wrap-around planning and supports” to achieve the goals of older adults and their caregivers by coordinating care within primary care teams, across care teams (e.g. primary care and specialist care providers) and between primary care teams and community services (e.g. adult day program) (
      • Craig C.
      • Eby D.
      • Whittington J.
      Care coordination model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series (white paper).
      ,
      • Singer S.J.
      • Burgers J.
      • Friedberg M.
      • Rosenthal M.B.
      • Leape L.
      • Schneider E.
      Defining and measuring integrated patient care: Promoting the next frontier in health care delivery.
      ). The essential elements of care coordination include: 1) comprehensive needs assessment of a person’s need, including medical history and examination and functional and social assessment; 2) individualized care planning jointly with the older adult, caregiver and the care team; 3) facilitation of access to needed medical care and community-based services; and 4) regular communication and monitoring (
      • Rich E.
      • Lipson D.
      • Libersky J.
      • Parchman M.
      Coordinating care for adults with complex care needs in the patient-centred medical home: Challenges and solutions (white paper).
      ).
      The optimal approach to care coordination for older adults with diabetes, who would benefit most and what outcomes should be measured (and are important to older adults) are all poorly understood (
      • Smith S.M.
      • Wallace E.
      • O'Dowd T.
      • Fortin M.
      Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.
      ,
      • Munshi M.N.
      • Meneilly G.S.
      • Rodríguez-Mañas L.
      • et al.
      Diabetes in ageing: Pathways for developing the evidence base for clinical guidance.
      ,
      • Sinclair A.J.
      • Abdelhafiz A.
      • Dunning T.
      • et al.
      An international position statement on the management of frailty in diabetes mellitus: Summary of recommendations.
      ). Furthermore, in the current context of pandemic recovery and an accelerated implementation of virtual care in Canada and internationally, it is important to determine how care coordination for this population could be optimized through virtual platforms (
      • Bhatia R.S.
      • Chu C.
      • Pang A.
      • Tadrous M.
      • Stamenova V.
      • Cram P.
      Virtual care use before and during the COVID-19 pandemic: A repeated cross-sectional study.
      ,
      • Wosik J.
      • Fudim M.
      • Cameron B.
      • et al.
      Telehealth transformation: COVID-19 and the rise of virtual care.
      ,
      • Mcohari-Greenberger H.
      • Pande R.L.
      Behavioral health in American during the COVID-19 pandemic: Meeting increased needs through access to high quality virtual care.
      ,
      • Stamenova V.
      • Chu C.
      • Pang A.
      • et al.
      Virtual care use during the COVID-19 pandemic and its impact on healthcare utilization in patients with chronic disease: A population-based repeated cross-sectional study.
      ,
      • Kim S.
      • Kim J.A.
      • Lee J.Y.
      International trend of non-contact healthcare and related changes due to COVID-19 pandemic.
      ). To our knowledge, no systematic or scoping reviews have been done to inform best practice guidance for care coordination of older adults with diabetes. Thus, the purpose of this scoping review is to understand the breadth of the literature on how care coordination is implemented in older adults with diabetes to inform practice and future areas of research on in-person and virtual care coordination.

      Review questions

      In the literature regarding care coordination for community-dwelling older adults with diabetes and their family caregivers:
      • 1.
        How is implementation of care coordination reported in literature?
      • 2.
        How is care coordination commonly evaluated?

      Inclusion criteria

      To be included, studies had to report on care coordination (or case management) activities for community-dwelling older adults with diabetes and their family caregivers. The population included community-dwelling older adults with a mean age ≥65 years, with type 1 or type 2 diabetes and with or without multiple chronic conditions. Quantitative studies, qualitative studies, mixed-methods studies, literature reviews, protocol articles and grey literature were included (
      • Adams J.
      • Hillier-Brown F.C.
      • Moore H.J.
      • et al.
      Searching and synthesising 'grey literature' and 'grey information' in public health: Critical reflections on three case studies.
      ,
      • Soobiah C.
      • Cooper M.
      • Kishimoto V.
      • et al.
      Identifying optimal frameworks to implement or evaluate digital health interventions: A scoping review protocol.
      ). However, grey data (i.e. tweets, blogs and podcasts) were excluded (
      • Adams J.
      • Hillier-Brown F.C.
      • Moore H.J.
      • et al.
      Searching and synthesising 'grey literature' and 'grey information' in public health: Critical reflections on three case studies.
      ). Care coordination that occurred exclusively within in-patient or long-term care settings was excluded. Conference abstracts, theses, dissertations and letters to the editor were also excluded.

      Methods

      The study was conducted using established scoping review methods outlined in Chapter 11 of the Joanna Briggs Institute Manual for Evidence Synthesis (
      • Peters M.D.J.
      • Godfrey C.
      • McInerney P.
      • Munn Z.
      • Tricco A.C.
      • Khalil H.
      Scoping reviews (2020 version).
      ). The objectives, inclusion criteria and methods for this scoping review were specified in advance and registered as a protocol on the Open Science Framework on July 13, 2021 (
      • Foster M.E.D.
      • Deardorff M.A.
      ).

      1. Search strategy

      A database search strategy was developed in consultation with a health sciences librarian (refer to Supplementary Table 1). Keywords and database terms were created for the concepts of care coordination, older adults and diabetes. A database search was performed across Medline, EmCare, CINAHL and Embase. Additional articles were located through hand-searching of reference lists. A targeted grey literature search was undertaken of relevant professional practices websites such as the International Diabetes Federation (refer to Supplementary Table 2) (
      ). Only articles in English or translated into English were included. All published and grey literature were restricted to a publication date from the years 2000 to 2021 to reflect the re-conceptualization of care coordination as broader than coordination of medical care related to the emergence of the concept of integrated health and social care in the research literature (
      • Kodner D.L.
      • Kyriacou C.K.
      Fully integrated care for frail elderly: Two American models.
      ). Authors were contacted by e-mail for additional information when required.

      2. Sources of evidence screening and selection

      Source selection at both title and abstract and full-text screening stages was done independently by at least 2 reviewers using Covidence software (M.N., A.S., C.A.). All disagreements throughout title, abstract and full-text screening were resolved through a consensus-based discussion between reviewers (M.N., A.S., C.A.).

      3. Data extraction

      The following variables were independently extracted by 3 authors (M.N., A.S., C.A.): author, year, country, objectives, population, study design, care coordination intervention, care coordination provider, context, reported outcomes, key findings, study limitations and source of funding. To minimize bias during the data extraction process, 2 independent authors completed a pilot extraction of 4 articles (A.S., C.A.) and the extractions were reviewed for quality and consistency by the first author.

      4. Data Analysis

      Based on the results of the scoping review, the following components were used to narratively present the findings: 1) population identification, 2) care coordination type, 3) comprehensive needs assessment, 4) individualized care planning, and 5) regular communication and monitoring. Outcomes of care coordination were analyzed by frequency and presented in a stacked bar graph. To identify the preferences, barriers, facilitators and outcomes associated with care coordination, common themes across the qualitative results of the mixed-methods and qualitative articles were identified and narratively summarized.

      Results

      A total of 7,353 articles were identified through the database search, and, after duplicate deletion, 4,870 articles were screened by title and abstract. After excluding 4,517 articles, 353 full-text articles were screened for eligibility and 37 articles were included. Five additional articles were identified through hand-searching of reference lists, for a total of 42 included articles. No best practice guidelines or other grey literature located met the inclusion criteria. Figure 1 presents an overview of the selection process.
      Figure thumbnail gr1
      Figure 1A flowchart detailing the study selection process. Adapted from Page et al, 2021 (
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.
      ).

      Article characteristics

      Included studies were published between 2005 and 2020 and conducted primarily in the United States (n=32), but also in Canada (n=3), China (n=3), Spain (n=1), Sweden (n=1), Italy (n=1) and Australia (n=1). The methodologies used were quantitative (n=32), qualitative (n=6), mixed methods (n=3) or reviews (n=1). Table 1 presents brief summaries of the included studies. Of the studies evaluating care coordination interventions (n=32), most (n=23) evaluated newly designed interventions (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Min L.
      • Cigolle C.T.
      • Bernstein S.J.
      • et al.
      Diabetes care improvement in pharmacist-versus nurse-supported patient-centered medical homes.
      ,
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ), as compared with other studies (n=9) exploring the impact of care coordination, which was part of usual care in the settings where the research was conducted (
      • Andrich D.
      • Foronda C.
      Improving glycemic control and quality of life with diabetes self-management education: A pilot project.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Benzer J.K.
      • Gurewich D.
      • Singer S.J.
      • et al.
      A mixed methods study of the association of non-Veterans Affairs care with veterans' and clinicians' experiences of care coordination.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ).
      Table 1Data extraction table for the included studies (n=42)
      Author, year, countryAimMethodologyPopulation characteristicsCare coordinationReported outcomes
      Andrich and Foronda, 2020, USATo improve glycemic control and QoL of Medicare patients aged ≥65 years of with T2DM.Practice improvement project, CPMedicare outpatients of endocrinology clinic (n=24), mean age 74 years, 62.5% male and A1C of ≥7% (mean 7.7%, SD=8).NPs provided 1 session of diabetes self-management education and support and goal setting, with a 4-week follow up, and care coordination.Fasting blood glucose decreased from 146.2 (SD=18.7) to 136.0 (SD= 17.1) mg/dL (p<0.05). Overall diabetes-specific quality of life improved significantly (p<0.05).
      Barnett et al, 2006, USATo assess health-care use among veterans with T2DM in a care coordination–home telehealth programRetrospective concurrent matched cohort study, CPVeterans from VA medical centres at high risk for hospitalization or ED visits (n=391 treatment, n=391 control), with mean age 68.1 years (treatment).Nurse care coordinators (RN or NP) monitored telehealth data, called patients, performed patient assessments, placed new medication orders, helped manage medications, scheduled appointments and reminded patients of appointments.Treatment group had statistically significant reductions in likelihood of all-cause (38.8% to 30.0%) and DM-related hospitalizations (35.3% to 26.9%).
      Barnett et al, 2007, USATo assess the cost–utility of a care coordination–home telehealth program.Retrospective, pre–post cohort study, CPVeterans from VA medical centres at high risk for hospitalization or ED visits (n=470), with mean age 68.2 years and 99% male.RN or NP care coordinators monitored telehealth data, called patients, performed patient assessments, placed new medication orders, helped manage medications, scheduled appointments and reminded patients of appointments.The overall mean incremental cost-effectiveness ratio for the program at 1 year was $60,941. The program was cost-effective for one third of participants.
      Bayliss et al, 2008, USATo explore processes of care desired by elderly patients with multiple morbidities that may present competing demands for patients and providers.Qualitative studyCommunity-dwelling older adults aged ≥65 years, and had (at minimum) diabetes, depression and osteoarthritis (n=26), with 46% between 65 and 74 and 54% between 74 and 84 years of age, and 50% male.NAParticipants’ desired processes of care included the need for convenient access to providers, providers with a caring attitude, clear communication of individualized care plans, support from a single coordinator of care and continuity of relationships.
      Bazzano et al, 2018, USATo understand the perspectives of health-care providers and system administrators and identify challenges and facilitators to the successful implementation of non–face-to-face long-term care management programs.Qualitative studyCare providers, including physicians (n=12) and nurses (n=4), and staff, administrators or billing specialists (n=4).NAHealth system personnel view non–face-to-face care as potentially providing value for patients and addressing systemic needs yet challenging to implement in practice. Barriers include major time commitment and patient needs extending beyond the program, whereas facilitators include the strategic use of resources in an already constrained environment.
      Bazzano et al, 2019, USATo investigate views on non–face-to-face care management held by elderly patients with diabetes and other chronic conditions.Qualitative studyT2DM patients with at least 1 comorbid condition, in an in-home virtual setting (n=30), mean age 68.3 years and 33% were male.RNs (and other clinic staff) made regular phone calls between patients, developed and reviewed care management plans and connected patients to resources when needed.Patient engagement and enthusiasm influenced positively by perceived self-sufficiency and self-efficacy. Patients preferred support in changing behaviours surrounding diet and nutrition, as opposed to simply education. Finally, patients expressed the value of speaking with providers in person (vs non–face-to-face), and of having personal, caring relationships with PCPs.
      Benzer et al, 2019, USATo determine how cardiovascular and mental health comorbidities relate to patient-centred coordinated care in the VA department.Observational study using patient surveysVeteran patients from 29 VA medical centres with T2DM and cardiovascular and mental health comorbidities (n=5,807), mean age 67.92 years, 90.8% male and 4.2% sex not reported.Clinician and clinic staff coordinated care through organizational processes, procedures and information exchange, as well as formal relationships between organizations such as contracts, formal relationships among parts of organizations such as services or clinics and informal relationships among people.Based on patients’ perceptions of integrated care survey, mental health comorbidities were significantly associated with lower patient experiences of coordinated care. Higher severity comorbidities were associated with more knowledge fragmentation, lower treatment-related communication, greater information flow to specialists and better hospital transitions.
      Benzer et al, 2020, USATo determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings.Mixed methods, CPVeteran patients with T2DM and either cardiovascular or mental health comorbidity from 8 VA sites, or non-VA clinics (n=5,807), mean age 67.92 years and 90.8% male (same sample as Benzer et al, 2019).The effectiveness of care coordination by clinicians and clinic staff across VA and non-VA settings depending on the degree to which VA coordination is prioritized, how it structured its regional non-VA networks, what mechanisms it implemented to facilitate coordination, what barriers to coordination it removed and how VA measures the coordination components of quality of care.Based on patients’ perceptions of integrated care survey, veterans who received both VA and non-VA care reported significantly worse care coordination experiences (0.11–0.24 lower scores) than veterans only receiving care within the VA department. Clinicians identified challenges such as limited information exchange capabilities, and bureaucratic and opaque procedures that adversely impacted clinical decision-making.
      Brown et al, 2016, USATo describe the successful implementation of a new model of chronic disease management.Quasi-experimental design, NIPatients with high-risk diabetes from a virtual RN outreach clinic in the VA department (phase 1: n=24, intervention, n=28 historical controls; phase 2: n=155), mean age 66 years, 93.5% male and A1C of >9% (mean 9.646, SD=1.73).Phase 1: RNs and NPs coordinated care, including establishing individualized A1C goals, providing education, coaching and support; adjusting medications; and reviewing of patients’ self-monitored blood glucose data transmitted via home telephone devices daily. Phase 2: RNs received additional education to provide medication titration. NPs entered insulin adjustment orders.Phase 1: Time to achievement of A1C goals was significantly improved in the intervention group (p<0.001) vs historic controls. Phase 2: Mean baseline A1C was reduced from 9.6% to 7.7% in the intervention group.
      Chumbler, Neugaard et al, 2005

      USA
      To report on the impact of a VHA program that implemented care coordination enhanced by CCHT in a large group of veterans with DM across 4 sites.Retrospective, single-group study design, CPVeteran patients who were frail with diabetes in the VA department, at high risk for expensive care service visits, in an in-home virtual setting (n=445), mean age 68.4 years and 98.7% male.Patients answered questions daily using an in-home messaging device containing disease management dialogues, and care coordinators reviewed responses daily to determine the risk for health-care emergencies. Patients treated holistically. In the case of comorbidities, care coordinators monitored difficult-to-manage conditions more intensely; in rare cases, 2-way audiovisual communication was used.The intervention resulted in a statistically significant reduction in the proportion of patients hospitalized (50% reduction), a reduction in emergency room use (by 11%), a reduction in average bed days of care (by an average of 3 days) and improvement in health-related quality of life in the domains of role–physical functioning, bodily pain and social functioning.
      Chumbler, Vogel et al, 2005, USATo examine the effectiveness of a VA patient-centred CCHT program as an adjunct to treatment for veterans with diabetes.Retrospective, concurrent matched cohort study design, CPVeterans with diabetes in the VA department at high risk for expensive, multiple care visits, in an in-home virtual setting, (n=800 total, 400 treatments, 400 in comparison group), with mean age 68.2 years (treatment).RN or NP care coordinators managed treatment, equipped veterans with self-management skills and attempted to increase preventive service use. They also monitored patients’ daily responses to a dialogue box that asked them health status questions to determine whether it was necessary to call the patient or facilitate a provider appointment.At 1 year post-enrolment, there was a significant difference between treatment and comparison groups in terms of needs-based primary care visits, increasing in the treatment group by 7.6% and decreasing in the comparison group by 12% (p<0.01); in a subgroup analysis that was controlled for A1C, the treatment group had a lower likelihood of hospitalizations vs the comparison group.
      Chumbler et al, 2009, USATo assess the effectiveness of the CCHT program in reducing mortalityRetrospectively matched intervention and control groups, CPVeterans with diabetes from the VA department, in an in-home virtual setting, (n=387 treatment, n=387 control) and mean age 68 years (for both treatment and control groups).Patients answered questions daily about symptoms and health status using an in-home messaging device, and RN and NP care coordinators monitored answers daily. Based on this, coordinators placed telephone calls to each patient, made physician referrals, consulted physicians, placed orders for new medications, helped manage medications and scheduled VA clinic appointments.There were significantly more deaths in the control group (26%) vs the intervention group (19%); there was longer survival for the intervention group vs the control group (mean survival time 1,348 vs 1,278 days, p=0.015). The telemonitoring program was associated with reduced 4-year all-cause mortality (hazard ratio=0.7, p=0.013).
      Dang et al, 2007, USATo evaluate telemedicine in diabetes management and education in older adults from different ethnic backgrounds.Pilot study of a care program, NICommunity-dwelling patients with DM receiving primary care, aged ≥60 years (n=41) and mean age 72 yearsNPs and licensed social workers coordinated care, which included assessment, planning, coordination and follow-up of multiple health-care services for patients and ensuring the services were received. They also monitored patient data received via an in-home messaging device daily, which included patients’ responses to questions regarding blood sugar and answers to educational questions.Mean A1C was 7.6% before enrolment, and 7.3% after 9 months (p=0.09), with the greatest decrease occurring in African Americans (0.65%, p=0.05). Total hospital admissions decreased from 31 pre-enrolment to 25 post-enrolment (p=0.0002). Bed days of care decreased from 368 to 149 (p=0.0002).
      Fagan et al, 2010, USATo examine the effects of an intervention comprising (1) practice-based care coordination program, (2) augmented by pay for performance for meeting quality targets and (3) complemented by a third-party disease management on quality of care and resource use. for older adults with diabetes.Quasi-experimental, longitudinal study, NIOlder adults with diabetes in 9 primary care practices, (n=20,943 total, n=1,587 intervention, n=19,356 comparison), mean age 74.6 years (intervention) and 42.2% were male (intervention)RNs, licensed practical nurses and medical assistants coordinated care onsite, and served as a liaison between PCPs and call centre nurses. Coordinator duties included alerting physicians to quality improvement opportunities, requesting hospital or specialists’ records and reviewing and conveying information to call centre nurses. so that they could follow up with patients.Intervention sites had significantly greater improvements in A1C (p<0.0001) and LDL (p<0.01) vs the control group. Measures for quality of care, utilization and cost were not significantly different between the 2 study groups.
      Gabbay et al, 2006, USATo measure the impact of a patient-oriented structured approach to care coordination and patient education and counselling on improvements in BP, glycemic control, lipids, complication screening and DM-related distress.RCT, NIPrimary care patients with T2DM managed by insulin or hypoglycemic agents (n=332 total, n=150 intervention, n=182 control), with a mean age 65 years (intervention), 57% male (intervention) and baseline A1C of 7.4%.RN coordinated care including the following activities: behavioural goal-setting; individualized care planning; providing self-management education and surveillance; making phone calls to patients; providing referrals to specialists, dietitians or certified diabetes educators; ordering protocol-driven laboratory tests; tracking clinical outcomes; and making clinical recommendations.After 1-year, BP decreased significantly from 137/77 to 129/72 mmHg in the intervention group, compared with an increase in BP in the control group from 136/77 to 138/79 mmHg. Problem areas in diabetes scores, assessing diabetes-related distress, significantly improved in the intervention group (23 to 10). Complication screening improved significantly in the intervention group vs the control group. A1C and LDL did not change significantly.
      He et al, 2017, ChinaTo investigate the frequency of follow-up visits and contents of care for case management of patients with T2DM in Chongqing, China, in terms of regional practice guideline, and to analyze factors associated with the use of care.Observation study using patient surveysPrimary care patients with T2DM of either a township near a hospital, or far from one (n=496); 76.4% were >60 years of age and 40.32% were maleNAOver 1-year, 65% of participants had at least 4 follow-up visits. The proportions of patients having recommended tests were 8%, 54%, 45% and 44% for A1C, blood lipid test, screening for nephropathy and eyes, respectively.
      Ishani et al, 2011, USATo determine whether nurse case management with a therapeutic algorithm could effectively improve rates of control for hypertension, hyperglycemia and hyperlipidemia vs usual care among veterans with diabetes.RCT, NIDiabetic patients in primary care through the VA medical centre or affiliated outpatient clinics, in-home virtual intervention setting (n=278 intervention, n=278 usual care), mean age 64.9 years (intervention), 99.6% male (intervention), average A1C 8% (intervention).Nurse case managers established lifestyle modification goals and personal action plans with patients, adjusted patient medications, made telephone calls, reviewed patients’ in-home BP measures, reviewed patient progress for blood glucose, lifestyle and BP goals, monitored adverse events associated with therapy and notified PCPs of medication changes.A greater number of individuals in the intervention group achieved control over all 3 outcomes of A1C, LDL and BP vs the usual-care group (21.9% vs 10.1%, p<0.01). A greater number of intervention patients vs usual-care patients achieved individual treatment goals for A1C (73.7% vs 65.8%, p=0.04) and BP (45% vs 25.4%, p<0.01), but not for LDL (57.6% vs 55.4%, p=0.61).
      Izquierdo et al, 2007, USATo examine the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes.RCT, NIOlder patients with diabetes living in upstate New York, receiving an in-home virtual intervention (n=338), 43% male and mean A1C of 7%.Nurse case managers coordinated care and coupled with dietitians and endocrinologists. Case managers reviewed patient responses to an in-home telemedicine unit; engaged in televisits every 4–6 weeks to discuss medications, BP and glucose readings; and made clinical recommendations to PCPs.Over 36 months, 67 medically urgent situations were identified and addressed (1.9 events/month). Some of these were potentially life-threatening, including drug contraindications (n=24), other medical urgent situations (n=19) and medically urgent conditions like unstable angina (n=24).
      Jia et al, 2009, USATo assess the longitudinal effect of the VA CCHT program by determining the extent to which it was associated with a lower probability of preventable hospitalization use by veterans with DM over a 4-year period.Retrospective matched treatment–control study, CPVeteran patients with diabetes from a VA medical centre who were of high treatment priority (n=387 treatment, n=387 control), mean age 67.6 years and 98.3% male.NP and RN care coordinators monitored patient responses received daily from an in-home messaging device, made telephone calls to patients, arranged referrals with physicians, scheduled VHA clinic appointments, placed new medication orders, helped with medication management, reminded patients of clinic appointments and assisted with technology difficulties.After 4 years, the treatment group had significantly fewer preventable hospitalizations (0.7 vs 1.0), a lower crude death rate (19.4% vs 26.4%) and longer survival time (1,349.4 days vs 1,278.2 days) vs the control group.

      .
      Jia et al, 2011, USATo assess the effects of the CCHT program for diabetes on the average number of inpatient stays and outpatient clinic visits over a follow-up period of 48 months.Longitudinal study with quasi-experimental design, CPVeterans with diabetes of VHA medical centres (n=387 treatment, n=387 control), mean age 68 years (treatment), and 99% male (treatment)Care coordinators monitored patient information received daily from a home telehealth device regarding symptoms and health status, made telephone calls to patients, arranged referrals with physicians, scheduled VHA clinic appointments, placed patient medication orders, helped with medication management, reminded patients of clinic appointments and assisted with technology difficulties.Compared with controls, intervention group patients were less likely to be admitted for inpatient care at 6- month (p<0.001) and 12-month (p<0.01) follow ups, and consistently more likely to visit outpatient clinics (p<0.001) during the complete 48-month follow-up period. The likelihood of an increase in outpatient utilization tended to decline over time.
      Lo et al, 2016, AustraliaTo explore the perspectives of patients and their carers on the factors influencing healthcare of those with comorbid diabetes and CKDQualitative studyParticipants with comorbid DM and CKD from Australian tertiary hospital health services, (n=58), median age 66 years and 70.69% maleFocus groups conducted to understand patient perspectives on care coordination provided by PCPs, potentially coordinating with specialists, pharmacists, social workers, nurse educators and others.Patient-level factors influencing care were self-management, socioeconomic status and adverse experiences related to comorbid diabetes and CKD; health service–level factors affecting care were prevention and awareness of comorbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment and poor recognition of psychological comorbidity.
      Markle-Reid et al, 2016, CanadaTo examine the feasibility of implementation in practice (primary) and the feasibility of study methods and potential effectiveness (secondary) of the Aging, Community, and Health Research Unit–Community Partnership Program.Mixed methods, NICommunity-dwelling older adults with T2DM, diagnosed with at least 2 additional chronic conditions and receiving in-home care (n=36), 33% were 65–69 years old and 14% were ≥80 years old, and were 44% male.RN and RD coordinators offered 4 in-home visits and 6 monthly group sessions; facilitated access to services and supports; and coordinated communication among participants, caregivers, the program team and PCPs. Coordinators also met monthly with a team for case conferences to develop client-centred care plans.Participants and providers viewed the program as acceptable and feasible. Participants had a higher short-form health survey physical component summary score at 6 months vs baseline (difference 3.0), and median costs for diabetes care increased over 6 months.
      Markle-Reid et al, 2018, CanadaTo compare the effect of a 6-month, community-based intervention with that of usual care on QoL, depressive symptoms, anxiety, self-efficacy, self-management and health-care costs in older adults with T2DM and 2 or more comorbidities.RCT, NICommunity-dwelling older adults with T2DM, diagnosed with at least 2 additional chronic conditions (n=200 total, n=101 intervention, n=99 control), 32.5% between 65 and 69 years, 40% between 70 and 74 years, and 27.5% >75 years of age, and 42.5% male (intervention).RN and RD care coordinators provided up to 3 in-home visits, and monthly group wellness sessions. Coordinators also engaged in monthly case conferences with team members, as well as ongoing nurse-led care coordination.The 6-month intervention significantly improved QoL and self-management, and reduced depressive symptoms, without increasing total health-care costs.
      Mateo-Abad et al, 2020, SpainTo evaluate, in the Basque Country, the impact of the Care Well integrated care model for older patients with multimorbidity.Mixed methods, NIComplex patients ≥65 years of age with at least 2 chronic conditions (1 of which was chronic obstructive pulmonary disease, congestive heart failure or DM), treated across home, hospital, primary care and virtual settings (n=200 total, n=101 intervention, n=99 control), mean age 79.4 years, 63% male, and mean A1C of 6.8%.Nurse case managers worked with a multidisciplinary care team to identify frail older individuals, conduct comprehensive baseline assessments, define therapeutic plans, coordinate hospital discharge, communicate with health-care providers and empower patients through home-based care.The intervention reduced the number of hospitalizations and emergency department visits and increased the number of primary care contacts. Clinical changes such as significant decreases in body mass index and blood glucose levels were observed. Satisfaction level was high for stakeholders.
      McCants et al, 2019, USATo determine the impact of integrated case management services compared with usual treatment for patients diagnosed with diabetes and concomitant CHF.Retrospective, descriptive study, NIAdults with CHF and DM, between hospital and home settings, (n=68 total, n=49 intervention, n=19 usual treatment), and mean age 77.8 years (SD=11.7) (intervention) and 53.1% male.Social worker and nurse case managers prioritized discharge needs and assessed, planned, implemented, evaluated and interacted to devise cohesive care plans to reduce costs and increase quality of care and coordinated transportation and home health.Of the intervention participants, 81.6% did not re-admit within 30 days, whereas only 47.4% of usual-treatment participants did not re-admit (p=0.012).
      Miklavcic et al, 2020, CanadaTo evaluate the effect of a 6-month community-based intervention vs usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management and health-care costs in older adults with T2DM and 2 or more comorbidities.Pragmatic RCT, NIOlder adults with T2DM and 2 or more chronic conditions, from in-home and community agency settings (n=132 total, n=70 intervention, n=62 usual care), 58% between 65 and 74 years of age, 42% ≥75 years of age and 45% male.RN and RD care coordinators provided up to 3 in-home visits, 6 monthly community group sessions and coordination through linking the client to community services.No significant group differences were seen in the change from baseline and 6 months in physical functioning (p=0.56), mental functioning (p=0.30) or other secondary outcomes.
      Min et al, 2017, USATo test for measurable improvement over time in diabetes care quality and utilization during implementation of PCMHs at the University of Michigan Health System in 2009, including 1 year pre- and 1 year post- implementation.Longitudinal cohort study, NIPatients with diabetes in primary care (n=2,221), mean age 71.6 years (pharmacy-led PCMHs), mean age 70.0 years (nurse-led PCMHs), 45.5% male (pharmacy-led PCMHs), and 43.6% male (nurse-led PCMHs).Pharmacist and nurse care coordinators provided self-management support and improved patient communication, which included standing lab-order sets, note templates, patient handouts and database and flow sheets to track improvement.Quality of care improved, and utilization decreased over 2.5 years. Both pharmacy and nurse-led coordination improved LDL and DBP by 2.5 years, although the trajectory differed. Only the pharmacy-led approach decreased primary care visits.
      Mohr et al, 2019, USATo examine how organizational coordination measures, reported by PCPs, were associated with patient experiences of care coordination.Cross-sectional surveysVA patients with T2DM, and one of either hypertension, congestive heart failure, depression/anxiety or severe mental illness or PTSD, from the VHA, (3,183 patients matched to 233 PCPs), 71.9% ≥65 years of age, 91.1% male and 46.8% with A1C >7%.RNs and licensed practical nurses provided care coordination.Patient ratings of specialist knowledge management and knowledge integration were significantly lower when either PCPs did not use feedback coordination, or rated feedback coordination lower. Teamwork was significantly related to specialist knowledge management (b=0.06), knowledge integration (b=0.04) and knowledge fragmentation (b=−0.04).
      Munshi et al, 2013, USATo evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control (same frequency of contact, but no advice provided).RCT, NIPatients with poorly controlled T1DM or T2DM, from a specialized diabetes outpatient clinic (n=100 total, n=70 intervention, n=30 attention control), mean age 75 years, 43% male (intervention) and baseline A1C of >8%.A diabetes educator care coordinator evaluated barriers to self-care, identified strategies to cope with barriers and made phone calls to educate, guide and follow up with patients. The control group educator made phone calls to participants, only discussing non–diabetes-related life events.Over 12 months, A1C decreased by 0.45% in the intervention group vs 0.31% in the control group. At 12 months, it decreased further in the intervention group (0.21% vs 0%) vs the control group. The intervention group showed additional benefits in measures of self-care, gait and balance and endurance compared with the control group. Diabetes-related distress improved in both groups.
      Ni et al, 2019, ChinaTo evaluate the effect of community nurse–led multidisciplinary team management on A1C, QoL, hospitalization and help-seeking behaviour in people with T2DM.Quasi-experimental trial, NICommunity individuals with T2DM, ≥35 years of age, in an in-home virtual setting (n=179 total, n=88 intervention, n=91 control), mean age 66.5 years, A1C of 7.08% (intervention).A nurse-led multidisciplinary team coordinated care, which included organizing group health education classes, providing individualized counselling via telephone and face-to-face follow-up visits and providing pamphlets and self-monitoring workbooks. Coordinators also served as liaisons between participants and PCPs.During the 24-month period, the intervention group had significantly reduced A1C (1.08%) vs the control group, which achieved an increase of 0.45% (p<0.001). The intervention group showed significant increases in QoL scores and seeking help from nurses, and a significantly larger decrease in hospitalizations vs the control group.
      Rafiq et al, 2019, SwedenTo describe the characteristics of heart/cardiac, nephrology, diabetes and mellitus patients and to explore the initial effects of a multidisciplinary and person-centred care on total care utilization.RCT, NIPatients in the outpatient centre with T1DM or T2DM, kidney disease and cardiovascular disease (n=42 intervention, n=35 control), mean age 74.2 years (intervention), 83.3% male (intervention).A multidisciplinary care team led by nurse managers, supported by registered practical nurse coordinated care by developing sustainable care management plans, engaging in twice-weekly case conferences with senior consultants and ensuring patients received all necessary treatment at a single location.Heart/cardiac, nephrology and diabetes mellitus patients were sicker than control group participants, but service utilization indicators were similar between the 2 arms. No between-group differences were statistically significant other than an increase in telephone visits in the intervention group.
      Regina et al, 2020, ItalyTo explore the potential of pharmacy services by community pharmacists in the management of T2DM alongside general and specialists’ medical practitioners to improve quality of diabetes care.Observational, noncontrolled pilot study, NIParticipants with T2DM from a rural community pharmacy, ≥18 years of age (n = 40), mean age 64.5 years and 50% male.Over 12 months, the pharmacist case manager received an individualized care plan from each participant’s physician. The pharmacist carried out examinations (electrocardiogram, fundus examination, self-analysis of blood and urine), booked examinations at accredited units and reported results to the physician.Patient adherence to the care plan increased significantly (98% in the first quarter and 100% in the remaining 3 quarters). Mean percentage change was −4% for A1C (SD=5), −10% for LDL (SD=7), −13% for SBP (SD=4) and −9% for DBP (SD=2). 80% of participants reported better patient information and easier accessibility to services.
      Shea et al, 2006,

      USA
      To examine the impact of the IDEATel intervention on clinical outcomes, including A1C, BP and lipid levels vs usual care.RCT, NIOlder adults ≥55 years of age, living in medically underserved areas of New York state, receiving in-home virtual care (n=1,665, n=844 intervention, n=821 usual care), mean age 71 years and 36.5% male (intervention).Nurse case managers (supervised by diabetologists) regularly communicated with patients via a Web-enabled computer and an existing telephone line, remotely monitored glucose and BP daily, provided patients with access to their own clinical data and provided access to an educational website.Over 1 year, the intervention group had significantly improved net reductions in A1C (0.18% net change, p=0.006), SBP and DBP (3.4 and 1.9 mmHg net change, p<0.001), and LDL (9.5 mg/dL net change, p<0.001) vs the control group.
      Shea et al, 2009,

      USA
      To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older, ethnically diverse, medically underserved patients with diabetes.RCT, NIOlder adults ≥55 years of age, from medically underserved areas of New York state, receiving in-home virtual care (n=1,665, n=844 intervention, n=821 usual care), mean age 71 years, 36.5% male (intervention) (same sample as Shea et al, 2006).Nurse case managers (supervised by diabetologists) regularly communicated with patients via a Web-enabled computer and an existing telephone line, remotely monitored glucose and BP daily, provided patients with access to their own clinical data, and provided access to an educational website (same care coordination as Shea et al, 2006).Over 5 years of follow up, the intervention significantly reduced A1C (p=0.001) by 0.29, LDL (p<0.01) by 3.84 and SBP and DBP by 4.32 mmHg and 2.64 mmHg (p = 0.024 and p<0.001), respectively.
      Shea et al, 2013, USATo examine the social impact of the telemedicine intervention effects in lower and higher socioeconomic status participants in the IDEATel study.RCT, NIOlder adults ≥55 years of age, living in medically underserved areas of New York state, receiving care in an in-home virtual setting (n= 1,665, n=844 intervention, n=821 usual care), mean age 71 years, 36.5% male (intervention) (same sample as Shea et al, 2006).Nurse case managers (supervised by endocrinologists) regularly communicated with patients via a Web-enabled computer and an existing telephone line, remotely monitored glucose and BP daily, provided patients with access to their own clinical data, and provided access to an educational website. Case managers contacted PCPs if a change in management was required (same sample as Shea et al, 2006).A1C was higher in lower income participants at baseline. However, after 5 years, the intervention did not seem to increase disparities. The lowest income group showed greater intervention effects in A1C (p=0.004) and SBP (p=0.023).
      Trief et al, 2006, USATo investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly, ethnically diverse diabetes patients.RCT, NIOlder adults ≥55 years of age with diabetes, living in medically underserved areas, in an in-home virtual setting, (n=1,665 total, n=844 intervention, n=821 usual care), mean age 70.8 years, 37.2% male and mean A1C 7.4%.Nurse case managers, under the supervision of an endocrinologist, monitored BP and blood glucose via a home telemedicine unit, video-conferenced with patients, provided patients with access to individualized graphic displays and educational content, and consulted with PCPs to make treatment planning decisions.At baseline, there was a significant correlation between depression and A1C. However, after 1 year, the intervention group reported a greater reduction in A1C compared with the control group, but depression did not predict changes in A1C.
      Trief et al, 2008, USATo understand the experiences of older patients with diabetes who participated in a telemedicine case management intervention.Qualitative studyOlder adults with DM who participated in in-home, virtual care coordination (n=40), mean age 67.93 years, 57.5% were male and mean A1C 7.38%.Nurse case managers coordinated care with the help of dietitians, including monitoring patient blood glucose and BP via web-enabled home telehealth units, video-conferencing with patients to educate and facilitate goal setting, providing support, and consulting with PCPs who made the final treatment decisions.Most patients enrolled in the program primarily because health-care providers encouraged them. Patients’ goals were to improve diabetes control, and they valued an emphasis on monitoring of health outcomes and supportive contact with staff.
      Trief et al, 2009, USATo assess whether diabetes self-efficacy relates to glycemic control (primary), and to BP and cholesterol (secondary), and whether a change in self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals.Analysis of pre-existing longitudinal data, NIOlder adults ≥55 years of age with T2DM, in an in-home, virtual setting, (n=1,665), mean age 70.82 years, 37.18% male and mean A1C 7.38% (same sample as Trief et al, 2006).Nurse and RD case managers collaboratively formulated a plan with patients to address BP, blood glucose and lipid control; monitored these outcomes through patient data uploaded using a home telemedicine unit; and regularly video-conferenced with patients to educate and discuss goals.The intervention significantly improved self-efficacy over time (p<0.0001). An increase in diabetes self-efficacy over time was related to improvement in glycemic control (p<0.0001), but not in BP or lipid levels.
      Tu et al, 2020, ChinaTo evaluate the effect of a nurse-coordinated hospital-initiated transitional care program on hypertension control for older people with diabetes in China.A single-blinded cluster RCT,

      NI
      Older adults with DM receiving care between hospital wards and community centres (n=270 total, n=135 intervention, n=135 control), mean age 70.9 years and 54.8% male.Discharge nurses, community nurses and PCPs coordinated hospital-initiated transitional care, including providing individualized post-discharge support and referring patients to specialist clinics for timely medication adjustment.The intervention group demonstrated a significant decrease in mean SBP (10.7 mmHg) DBP (4.1 mmHg) vs the control group. There were significant improvements in A1C, hypertension and diabetes knowledge, treatment adherence, QoL, hospital re-admission and emergency department visits in the intervention group vs the control group.
      Wakefield et al, 2011, USATo evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and hypertension.RCT, NIVeterans with comorbid T2DM and hypertension in VA department primary care (n=302 total, n=107 usual care, n=93 high-intensity intervention, n=102 low-intensity intervention), mean age 68 years and 98% male.RN care coordinators monitored patient responses on a home telehealth device daily for 6 months to determine whether patients required follow up. The low-intensity group received standard prompts, whereas the high-intensity group also received additional health questions and educational content.Over 6 months, A1C in both intervention groups decreased significantly vs the control group (p=0.03 and 0.02 for low- and high-intensity groups), but differences were not maintained at 12 months. High-intensity subjects had a significant decrease (p=0.001) in SBP vs the control group at 6 and 12 months.
      Walker et al, 2017, primarily studies from USA, 1 from Austria, 1 from UKTo explore home telemedicine interventions for the treatment of older adults with diabetes.Systematic reviewStudies including older adults with a mean age >65 years, with T1 or T2DM, with and without other chronic conditions and receiving virtual care.Care coordination interventions involved education, closed-loop feedback and communication, a home telemedicine device or unit, remote monitoring, use of a telephone or telephone line and motivational interviewing or coaching.The included studies suggest that case management or coordination can effectively decrease admissions, costs per person per year, mortality and cognitive decline in older adults with diabetes.
      Yeager et al, 2018, USATo provide insight into patient and provider experiences, specifically for the care of patients with diabetes and multiple chronic comorbidities.Qualitative studyPatients ≥65 years old with DM and at least 1 other chronic condition, and health-care providers implementing the program in a virtual setting, (n=14 patients, n=19 providers).Nurse case managers coordinated care through telephone, text, e-mail or patient portals, and had responsibilities such as answering patient questions, prescription management, appointment scheduling, billing and finance, self-care plans and coordination with and referral to other providers such as specialists or diabetes educators.Providers identified challenges such as the large time commitment required to coordinate care for complex patients, low patient literacy and technology proficiency and high patient psychosocial needs. Providers believed the program benefitted patients, and that it improved continuity of care. Patients reported positive experiences, such as the program being applicable to their needs.
      A1C, glycated hemoglobin; BP, blood pressure; CCHT, Care Coordination Home Telehealth; CKD, chronic kidney disease; CP, current practice; DBP, diastolic blood pressure; DEC, Diabetes Education Centre; DM, diabetes mellitus; IDEATel, Informatics for Diabetes and Education Telemedicine Project; LDL: low-density lipoprotein; NA, not applicable; NI, new intervention; NP, nurse practitioner; PCMH, patient centred medical home; PCP, primary care provider; QoL, quality of life; RCT, randomized control trial; RD, registered dietitian; RN, registered nurse; SBP, systolic blood pressure; T1, type 1; T2DM, type 2 diabetes mellitus; VA, Veterans Affairs; VHA, Veterans Health Affairs.
      Care coordination was primarily provided to patients from Veteran Affairs (VA) medical centres (n=13) (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Benzer J.K.
      • Gurewich D.
      • Singer S.J.
      • et al.
      A mixed methods study of the association of non-Veterans Affairs care with veterans' and clinicians' experiences of care coordination.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ,
      • Benzer J.K.
      • Singer S.J.
      • Mohr D.C.
      • et al.
      Survey of patient-centered coordination of care for diabetes with cardiovascular and mental health comorbidities in the Department of Veterans Affairs.
      ,
      • Mohr D.C.
      • Benzer J.K.
      • Vimalananda V.G.
      • et al.
      Organizational coordination and patient experiences of specialty care integration.
      ) or as a virtual service delivered by providers outside of the settings of care (n=11) (
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Bazzano A.N.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Barriers and facilitators in implementing non-face-to-face chronic care management in an elderly population with diabetes: A qualitative study of physician and health system perspectives.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ,
      • Walker C.L.
      • Kopp M.
      • Binford R.M.
      • Bowers C.J.
      Home telehealth interventions for older adults with diabetes.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ). Typical settings for care coordination delivery were community (n=8) (
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Bayliss E.A.
      • Edwards A.E.
      • Steiner J.F.
      • Main D.S.
      Processes of care desired by elderly patients with multimorbidities.
      ), primary care (n=5) (
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Min L.
      • Cigolle C.T.
      • Bernstein S.J.
      • et al.
      Diabetes care improvement in pharmacist-versus nurse-supported patient-centered medical homes.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • He M.
      • Gao J.
      • Liu W.
      • Tang X.
      • Tang S.
      • Long Q.
      Case management of patients with Type 2 diabetes mellitus: A cross-sectional survey in Chongqing, China.
      ), specialized outpatient clinics (n=3) (
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Andrich D.
      • Foronda C.
      Improving glycemic control and quality of life with diabetes self-management education: A pilot project.
      ) or from hospital to home (n=2) (
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Lo C.
      • Ilic D.
      • Teede H.
      • Cass A.
      • Fulcher G.
      • Gallagher M.
      • et al.
      The perspectives of patients on health-care for co-morbid diabetes and chronic kidney disease: A qualitative study.
      ). Most care coordination practitioners were registered nurses (RNs) (n=18) (
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ,
      • Lo C.
      • Ilic D.
      • Teede H.
      • Cass A.
      • Fulcher G.
      • Gallagher M.
      • et al.
      The perspectives of patients on health-care for co-morbid diabetes and chronic kidney disease: A qualitative study.
      ) or RNs working with nurse practitioners or licensed practical nurses (n=10) (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Mohr D.C.
      • Benzer J.K.
      • Vimalananda V.G.
      • et al.
      Organizational coordination and patient experiences of specialty care integration.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ). In some studies, diabetes educators, non–health-care professionals or clinic staff were the principal care coordinators (n=3) (
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ,
      • Benzer J.K.
      • Gurewich D.
      • Singer S.J.
      • et al.
      A mixed methods study of the association of non-Veterans Affairs care with veterans' and clinicians' experiences of care coordination.
      ,
      • Benzer J.K.
      • Singer S.J.
      • Mohr D.C.
      • et al.
      Survey of patient-centered coordination of care for diabetes with cardiovascular and mental health comorbidities in the Department of Veterans Affairs.
      ). Two studies had pharmacists as care coordinators (
      • Min L.
      • Cigolle C.T.
      • Bernstein S.J.
      • et al.
      Diabetes care improvement in pharmacist-versus nurse-supported patient-centered medical homes.
      ,
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ).

      Implementation of care coordination activities

      Population identification

      The majority (n=35) of studies identified a specific population of persons with diabetes as the intervention target, whereas the remaining (n=4) studies recruited adults of all ages with diabetes. The following populations were targeted: older adult veterans with diabetes (n=13) (
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Benzer J.K.
      • Gurewich D.
      • Singer S.J.
      • et al.
      A mixed methods study of the association of non-Veterans Affairs care with veterans' and clinicians' experiences of care coordination.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ,
      • Benzer J.K.
      • Singer S.J.
      • Mohr D.C.
      • et al.
      Survey of patient-centered coordination of care for diabetes with cardiovascular and mental health comorbidities in the Department of Veterans Affairs.
      ,
      • Mohr D.C.
      • Benzer J.K.
      • Vimalananda V.G.
      • et al.
      Organizational coordination and patient experiences of specialty care integration.
      ); older adults with diabetes and at least 1 other chronic condition (n=11) (
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Bazzano A.N.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Barriers and facilitators in implementing non-face-to-face chronic care management in an elderly population with diabetes: A qualitative study of physician and health system perspectives.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Bayliss E.A.
      • Edwards A.E.
      • Steiner J.F.
      • Main D.S.
      Processes of care desired by elderly patients with multimorbidities.
      ,
      • Lo C.
      • Ilic D.
      • Teede H.
      • Cass A.
      • Fulcher G.
      • Gallagher M.
      • et al.
      The perspectives of patients on health-care for co-morbid diabetes and chronic kidney disease: A qualitative study.
      ); Medicare patients in the United States with diabetes with or without other chronic conditions (n=9) (
      • Min L.
      • Cigolle C.T.
      • Bernstein S.J.
      • et al.
      Diabetes care improvement in pharmacist-versus nurse-supported patient-centered medical homes.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Andrich D.
      • Foronda C.
      Improving glycemic control and quality of life with diabetes self-management education: A pilot project.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Izquierdo R.
      • et al.
      Psychosocial outcomes of telemedicine case management for elderly patients with diabetes: The randomized IDEATel trial.
      ); and older adults with poorly controlled diabetes, as determined by a glycated hemoglobin (A1C) of ≥8% to 9% (n=2) (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ). The remaining studies included older adults (n=3) (
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ,
      • Walker C.L.
      • Kopp M.
      • Binford R.M.
      • Bowers C.J.
      Home telehealth interventions for older adults with diabetes.
      ) and adults of all ages (n=4) (
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • He M.
      • Gao J.
      • Liu W.
      • Tang X.
      • Tang S.
      • Long Q.
      Case management of patients with Type 2 diabetes mellitus: A cross-sectional survey in Chongqing, China.
      ).

      Care coordination type

      The most common types of care coordination occurred within health-care teams only (n=16) (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Min L.
      • Cigolle C.T.
      • Bernstein S.J.
      • et al.
      Diabetes care improvement in pharmacist-versus nurse-supported patient-centered medical homes.
      ,
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ,
      • Walker C.L.
      • Kopp M.
      • Binford R.M.
      • Bowers C.J.
      Home telehealth interventions for older adults with diabetes.
      ) and care coordination within and across care teams (n=12) (
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Andrich D.
      • Foronda C.
      Improving glycemic control and quality of life with diabetes self-management education: A pilot project.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ,
      • Bayliss E.A.
      • Edwards A.E.
      • Steiner J.F.
      • Main D.S.
      Processes of care desired by elderly patients with multimorbidities.
      ). Only 9 studies engaged in all 3 types of care coordination, coordinating within care teams, across care teams and between care teams and community resources (
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Benzer J.K.
      • Gurewich D.
      • Singer S.J.
      • et al.
      A mixed methods study of the association of non-Veterans Affairs care with veterans' and clinicians' experiences of care coordination.
      ,
      • Benzer J.K.
      • Singer S.J.
      • Mohr D.C.
      • et al.
      Survey of patient-centered coordination of care for diabetes with cardiovascular and mental health comorbidities in the Department of Veterans Affairs.
      ). One study coordinated care across care teams and the community (
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ).

      Comprehensive needs assessment

      Twenty-two studies conducted some form of a needs assessment (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Munshi M.N.
      • Segal A.R.
      • Suhl E.
      • et al.
      Assessment of barriers to improve diabetes management in older adults.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Andrich D.
      • Foronda C.
      Improving glycemic control and quality of life with diabetes self-management education: A pilot project.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ). Care coordinators conducted baseline medical assessments, reviewed patients’ medical and family health history and engaged in consultative case conferences with registered dietitians or endocrinologists, such as to determine needs. Coordinators also evaluated other patient needs to connect individuals to community resources, such as transportation or social services, but assessment of caregiver and social supports was not commonly evident.

      Individualized care planning

      Fourteen studies developed or reviewed individualized care plans as part of care coordination (
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • McCants K.M.
      • Reid K.B.
      • Williams I.
      • Miller D.E.
      • Rubin R.
      • Dutton S.
      The impact of case management on reducing readmission for patients diagnosed with heart failure and diabetes.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ). Care planning included lifestyle modification plans for weight loss, dietary changes and physical activity, hospital discharge plans, individualized medication plans and the establishment of health-oriented goals. Only 4 studies collaborated with family caregivers on care planning (
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ).

      Regular communication and monitoring

      Regular communication (n=28) was commonly implemented in care coordination. The most common type of communication was between care coordinators and patients. Three studies included in-home visits by care coordinators (
      • Markle-Reid M.
      • Ploeg J.
      • Fisher K.
      • et al.
      The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study.
      ,
      • Markle-Reid M.
      • Ploeg J.
      • Fraser K.D.
      • et al.
      Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity.
      ,
      • Miklavcic J.J.
      • Fraser K.D.
      • Ploeg J.
      • et al.
      Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: A pragmatic randomized controlled trial.
      ). However, most communication was done virtually (n=23), including: 1) weekly, biweekly or monthly telephone calls between the coordinator and patient (
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ); 2) daily messaging regarding health status via an in-home messaging device (
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ); and 3) 2-way video conferencing with patients (
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ). Other communications involved consultation and information sharing between care coordinators and primary care physicians (
      • Fagan P.J.
      • Schuster A.B.
      • Boyd C.
      • et al.
      Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • Rafiq M.
      • Keel G.
      • Lindgren P.
      • et al.
      Extreme consumers of health care: Patterns of care utilization in patients with multiple chronic conditions admitted to a novel integrated clinic.
      ,
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ).
      Regular monitoring of patients was also commonly implemented (n=24) and included monitoring and responding to lab results (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Mateo-Abad M.
      • Gonzalez N.
      • Fullaondo A.
      • et al.
      Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Ni Y.
      • Liu S.
      • Li J.
      • et al.
      The effects of nurse-led multidisciplinary team management on glycosated hemoglobin, quality of life, hospitalization, and help-seeking behaviour of people with diabetes mellitus.
      ,
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Barnett T.E.
      • Chumbler N.
      • Vogel W.B.
      • Beyth R.J.
      • Ryan P.
      • Figuero S.
      The cost-utility of a care coordination/home telehealth programme for veterans with diabetes.
      ,
      • Chumbler N.R.
      • Neugaard B.
      • Kobb R.
      • Ryan P.
      • Qin H.
      • Joo Y.
      Evaluation of a care coordination/home-telehealth program for veterans with diabetes: Health services utilization and health-related quality of life.
      ,
      • Chumbler N.
      • Vogel B.
      • Garel M.
      • Qin H.
      • Kobb R.
      • Ryan P.
      Health sevices utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ), medication management (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Tu Q.
      • Xiao L.D.
      • Fuller J.
      • Du H.
      • Ullah S.
      A transitional care intervention for hypertension control for older people with diabetes: A cluster randomized controlled trial.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Barnett T.E.
      • Chumbler N.R.
      • Vogel W.B.
      • Beyth R.J.
      • Qin H.
      • Kobb R.
      The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.
      ,
      • Chumbler N.R.
      • Chuang H.C.
      • Wu S.S.
      • et al.
      Mortality risk for diabetes patients in a care coordination, home-telehealth programme.
      ,
      • Jia H.
      • Chuang H.C.
      • Wu S.S.
      • Wang X.
      • Chumbler N.R.
      Long-term effect of home telehealth services on preventable hospitalization use.
      ,
      • Jia H.
      • Feng H.
      • Wang X.
      • Wu S.S.
      • Chumbler N.
      A longitudinal study of health service utilization for diabetes patients in a care coordination home-telehealth programme.
      ,
      • Yeager V.A.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Non-face-to-face chronic care management: A qualitative study assessing the implementation of a new CMS reimbursement strategy.
      ), ordering laboratory tests (
      • Gabbay R.A.
      • Lendel I.
      • Saleem T.M.
      • et al.
      Nurse case management improves blood pressure, emotional distress and diabetes complication screening.
      ), conducting physical examinations (
      • Regina R.L.
      • Pandolfi D.
      • Stabile N.
      • et al.
      A new case manager for diabetic patients: A pilot observational study of the role of community pharmacists and pharmacy services in the case management of diabetic patients.
      ) and daily virtual monitoring of blood pressure and blood glucose (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coordination and telemedicine improves glycaemic control in ethnically diverse veterans with diabetes.
      ,
      • Ishani A.
      • Greer N.
      • Taylor B.C.
      • et al.
      Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes.
      ,
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ).

      Virtual care

      A variety of technologies were used to deliver care coordination virtually from communication over the phone (
      • Bazzano A.N.
      • Wharton M.K.
      • Monnette A.
      • et al.
      Barriers and facilitators in implementing non-face-to-face chronic care management in an elderly population with diabetes: A qualitative study of physician and health system perspectives.
      ), remote-monitoring devices (
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ) or video-conferencing (
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ). The remote monitoring device used is a Web-enabled computer with 4 functions: video-conferencing, uploading of data from glucose and blood pressure monitoring devices, patient-facing clinical data and providing educational websites (
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ). The provision of virtual care was comprehensive, similar to in-person delivery, and included developing and reviewing care plans, sharing monitoring outputs with primary care and specialist providers, advising patients of medication changes and upcoming appointments and providing patient education and coaching (
      • Izquierdo R.
      • Meyer S.
      • Starren J.
      • et al.
      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Starren J.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.
      ,
      • Shea S.
      • Weinstock R.S.
      • Teresi J.A.
      • et al.
      A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study.
      ,
      • Shea S.
      • Kothari D.
      • Teresi J.A.
      • et al.
      Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: Findings from the IDEATel Study.
      ,
      • Trief P.M.
      • Morin P.C.
      • Izquierdo R.
      • et al.
      Depression and glycemic control in elderly ethnically diverse patients with diabetes: The IDEATel project.
      ,
      • Trief P.M.
      • Teresi J.A.
      • Eimicke J.P.
      • Shea S.
      • Weinstock R.S.
      Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: The IDEATel project.
      ,
      • Wakefield B.J.
      • Holman J.E.
      • Ray A.
      • et al.
      Effectiveness of home telehealth in comorbid diabetes and hypertension: A randomized, controlled trial.
      ,
      • Bazzano A.N.
      • Monnette A.M.
      • Wharton M.K.
      • et al.
      Older patients' preferences and views related to nonface-to-face diabetes chronic care management: A qualitative study from southeast Louisiana.
      ,
      • Trief P.M.
      • Sandberg J.
      • Izquierdo R.
      • et al.
      Diabetes management assisted by telemedicine: Patient perspectives.
      ).

      Outcomes assessed

      Across the 35 quantitative and mixed-method studies included, 56 unique outcomes were utilized to evaluate care coordination. Patient outcomes (n=31) were the most commonly measured, the most frequent being A1C (n=21) (
      • Brown N.N.
      • Carrara B.E.
      • Watts S.A.
      • Lucatorto M.A.
      RN diabetes virtual case management: A new model for providing chronic care management.
      ,
      • Dang S.
      • Ma F.
      • Nedd N.
      • Florez H.
      • Aguilar E.
      • Roos B.A.
      Care coo