ECHO for Diabetes and Multiple Chronic Conditions Study

For the intervention, an 18-month ECHO program of weekly videoconference sessions will mentor healthcare teams on complex care strategies for patients with DMMC, emphasizing evidence-based best practices related to common chronic conditions (e.g., diabetes, CKD, hypertension, hyperlipidemia and depression). Mentorship will be provided by a multidisciplinary team of experts including a patient representative, diabetes educator, endocrinologist, psychiatrist, a nephrologist/kidney disease and hypertension specialist, a clinical pharmacist, and a cardiology consultant. Each session will consist of a didactic presentation, de-identified patient case presentations, and questions and discussion.

The comparator will consist of 10 PMS FQHC clinics with healthcare teams practicing usual care according to PMS standard practices during the 18 months of the intervention arm.