The goal of this project was to outline best practices regarding the organization of diabetes care and services in the community in relation to the local context of services in Squamish, BC, Canada to create a foundation for future quality improvement work. The theoretical framework of personcentered care is essential to chronic disease management and underpins this work. The methods include: 1) A narrative literature review consisting of a database search, and 2) A gap analysis consisting of local data and an environmental scan. The Chronic Care Model is an evidence-based integrated care framework used to organize the findings of the narrative literature review and the gap analysis and to frame the recommendations (Clement et al., 2018). Based on the findings, evidence-based recommendations were created specific to the context of diabetes care in Squamish, BC creating the opportunity for meaningful future quality improvement work.