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Diabetes care according to the CCM, including the involvement of trained practice nurses, is a reasonable tool to improve care in the long-term. CCM training of the whole team is essential to overcome organisational challenges. Continuous team education, technical decision support, and recognition of the importance of these new structures in healthcare policy might improve the long-term clinical effect of the team approach.

Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study