My colleagues and I recently published a paper which describes how we created a model to show how people with diabetes become less dependent on primary care and more able self-managers.
We used maps created by general practice staff to show how their patients progress through the system following diagnosis.
In the current system, once treatment has been decided on, the frequency of appointments decreases and people are expected to self-manage with support from regular review appointments. Seeing the model and talking it through with GPs and others helped us to consider some of the shortfalls in the system.