“…Given that chronic care management is intended to improve both health service delivery and patient quality of life, research into facilitators of chronic care management has grown in recent years. This has resulted in the identification of several domains of interest: health information systems development [ 17 , 18 , 19 ], organized channels of communication [ 6 , 20 , 21 ], collaboration with specialists such as endocrinologists [ 22 , 23 , 24 ], relationship building with patients to improve engagement [ 6 , 25 ], involvement of community health workers and/or educators [ 20 , 26 , 27 ], telemedicine such as remote screenings [ 28 , 29 , 30 ], medication management [ 21 , 31 ], and establishment of clinic-community collaborations [ 6 , 18 ]. Potential barriers to implementing CCM programs include challenges addressing social needs of the patient that impact their self-management ability [ 6 ] and establishing provider buy-in for new processes and procedures [ 18 ].…”