Fiona McCaughan, RN, MS, is a nurse leader at Cambridge Health Alliance in primary care. Recently lead two primary care sites through Patient Centered Medical Home (PCMH) level 3 certification and PCMH Prime certification (integrating behavioral health into primary care). For past three years supported multi-facility learning collaborative with Harvard Medical School, Center for Primary Care as a leader and as the nurse planner. Gold Fellow Innovation Fellow for co-producing healthcare improvements for people with diabetes. Theory: Using a health coach model and employing motivational interviewing will create a collaborative environment in primary care for patients to develop and edit their care plans with their care team members. Successful chronic disease management and patient engagement are critical in improving health outcomes, reducing costs, improving the patient’s experience of care, and improving staff work life.