International Journal of Preventive Medicine (Int J Prev Med)2008-78021012019012320087802ENNursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, IsfahanNursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, IsfahanNursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, IsfahanEndocrinologist, Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, IsfahanIsfahan Social Welfare Organization, Isfahan Shariati Hospital, Heart SectionShahid Malakooti Polyclinic of Social Welfare Organization of Isfahan, Diabetes ClinicNurse of Shahid Malakooti Polyclinic of Social Welfare Organization of Isfahan, Diabetes ClinicDiabetologist of Diabetes Unit, Shahid Malakooti Polyclinic of Social Welfare Organization of Isfahan, Diabetes Clinic20190123<p><span class="fontstyle0"><strong>Background</strong>: </span><span class="fontstyle2">Reforming the health care system to improve suitable health care model for diabetic patients is essential. This study aimed to implement, identify, and overcome the challenges of implementing the Chronic Care Model in diabetes management in a clinic.</span></p><p><strong></strong><span class="fontstyle0"><strong>Methods</strong>: </span><span class="fontstyle2">This study is a qualitative technical action research with the Kemmis and McTaggart model including planning, action, reflection, observation, and revision plan which was conducted in the specialized polyclinic from 2015 to 2017 in Isfahan city – Iran. Data were gathered through qualitative and quantitative methods. Diabetes team and 17 patients with type 2 diabetes participated in semi-structured<br />interviews that were purposively chosen. Qualitative data were analyzed using content analysis and then quantitative data collected. </span></p><p><strong></strong><span class="fontstyle0"><strong>Results</strong>: </span><span class="fontstyle2">The qualitative fndings of this research are in fve main categories: System design upgrade, self-management upgrade, decision support, health care organization, and clinical information system upgrade. Results of quantitative data showed that most metabolic indicators like HbA1c have statistical meaningful changes (</span><span class="fontstyle3">P </span><span class="fontstyle2">value &lt; 0.05).<br /></span></p><p><span class="fontstyle0"><strong>Conclusions</strong>: </span><span class="fontstyle2">Implementing the Chronic Care Model became feasible despite serious challenges and two groups of ready and active team and active patients were developed. The study showed that one important lost link of diabetes management is underestimating the nurses’ capabilities in the management of this disease. Inevitably, serious investment on maximum use of nurses’ knowledge and skills in improving diabetes management will help diabetes care upgrade signifcantly.<br /></span></p><p><span class="fontstyle0" style="color: #00652e;">Keywords: </span><span class="fontstyle3">Action research, diabetes mellitus type II, disease management, patient‑centered care</span></p>http://ijpm.mui.ac.ir/index.php/ijpm/article/view/2000http://ijpm.mui.ac.ir/index.php/ijpm/article/download/2000/717717820