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Health Disparities Collaboratives
Diabetes
Changing Practice
Changing Lives
Diabetes
Contents
Acknowledgments .................................................................................................... 2
The Challenge........................................................................................................... 4
The Solution ............................................................................................................. 6
Care Model Checklist............................................................................................... 7
Self-Management ............................................................................................... 8
Decision Support ............................................................................................. 15
Clinical Information System............................................................................. 23
Delivery System Design.................................................................................... 35
Organization of Health Care .......................................................................... 41
© 2002, Diabetes 1.0
Produced by:
Institute for Healthcare Improvement
Community...................................................................................................... 49
In partnership with:
National Association of Community Health Centers
Care Model: Changes for Specific Populations ....................................................... 58
Improving Chronic Illness Care, a national program
of The Robert Wood Johnson Foundation
Improvement Model............................................................................................... 61
Centers for Disease Control and Prevention,
Division of Diabetes Translation
Aims ................................................................................................................ 62
Substance Abuse and Mental Health Services Administration
Measures.......................................................................................................... 64
State Diabetes Control Program
Changes ........................................................................................................... 69
National Diabetes Education Program
Bayer Corporation
Bibliography........................................................................................................... 70
List of Tools and Resources.................................................................................... 73
With support from:
Health Resources and Services Administration,
Bureau of Primary Health Care
DIABETES TRAINING MANUAL
1
Acknowledgments
Thanks to the Cluster Directors for their
expert review of this material — and for their
dedication to the health centers they guide
so skillfully.
Heidi Child, RN, MSN
Pacific West Cluster Collaborative Director
Program Director
California Primary Care Association
Sossity Fair, MPH, CHES
West Central Cluster Collaborative Director
Texas Association of Community Health Centers
Tracy Jacobs, RN
Mountain Plains Clinical Network Collaborative
Director
Community Health Association of
Mountain/Plains States
Julie Koppert, RNC, BSN, CDE
Thanks to the hundreds of health centers that have taken part in the Diabetes Collaboratives.
They led the way in testing and implementing a new approach to the care of people with diabetes,
and their impressive results have inspired many more to join the effort.
In particular, thanks to the following individuals who helped develop this manual by sharing
what they learned in the course of applying the Care Model to improving diabetes care and to
all those who gave their time and good ideas to the development of this resource.
Mary Jo Bloominger, MPAS
Susie Cook
Physician Assistant, Diabetes Team Leader
Community Health Care
Clinical Director
Columbus Neighborhood Health Center, Inc.
Katie Bogart, MSW
Denice Cora-Bramble, MD
Project Manager
Institute for Healthcare Improvement
Senior Medical Advisor
Health Resources and Services Administration
Bureau of Primary Health Care
Katherine Brieger, RD, CDE
Vice President – Community Initiatives
Hudson River Healthcare
Midwest Cluster Collaborative Director
Michigan Primary Care Organization/Midwest
Clinicians’ Network
Penny Carver, MEd
Wanda Montalvo, RN, MSN, ANP
Mady Chalk, PhD
Northeast Collaborative Director
Connecticut Primary Care Association
Janice Wilkerson, RN, CPHQ
Quality Management Consultant, Southeast
Cluster Collaborative Director
South Carolina Primary Health Care Association
Senior Vice President
Institute for Healthcare Improvement
Connie Davis, MN, ARNP
Associate Director for Clinical Improvement
Improving Chronic Illness Care
Paula Devitt, RN, CDE
Director of Health Education
La Familia Medical/Dental Center
Director
Office of Managed Care
Center for Substance Abuse Treatment
Maxine Henderson, RN
Roger Chaufournier
Lisa Homer, RN
President & CEO
Patient Information Systems
Patient Care Coordinator
Mountainlands Community Health Center
Cynthia Clark, MA
Cindy Hupke, RN, BS, MBA
Program Consultant
Division of Diabetes Translation
Centers for Disease Control & Prevention
IHI National Collaborative Director
Bureau of Primary Health Care
Health Disparities Collaboratives
Quality Improvement Director
Family Healthcare Center
DIABETES TRAINING MANUAL
2
Alvin Jackson, MD
John Pierson
Barbara Smith, MSN, RN, CS
Medical Director
Community Health Services
NE Cluster IS Director
Connecticut Primary Care Association
Family Nurse Practitioner
Union-Granger Primary Care
Matt Kanaracus and Karen LeDuc
Lynn Price, MSN, MPH, VD
Molly Soeby, MT, SC
Designers
Codesign
Director, Patient Services
Program Development Coordinator
Altru Health System
Lloyd Provost, MS
Jane Kelly, MD
Medical Epidemiologist
Centers for Disease Control and Prevention
Statistician
Associates in Process Improvement
Kathleen Reims, MD
Jane Landon, RN, MS
Quality Improvement Coordinator
Columbus Neighborhood Health Center, Inc.
Medical Director
People’s Clinic
Statistician
Associates in Process Improvement
CEO
Stewart Webster Rural HC, Inc.
Director, Health Disparities Collaboratives
Bureau of Primary Health Care
Charmaine Trujillo, RN
Veronica Richardson, RN, MSN
Elizabeth Magenheimer, MSN, APRN,
CNM, FNP, CDE
Chief, Clinical Branch/Division of Community
& Migrant Health
Health Resources & Services Administration
Bureau of Primary Health Care
Tricia L. Trinite, NP, MSPH
Sarah C. Richardson
Jerry Langley, MS
David M. Stevens, MD
Director of Chronic Disease Management
Grace Hill Neighborhood Health Center, Inc.
Operations Director, Internal Medicine
Mountain Park Health Center
Alan Tso, MD
Fair Haven Community Health Center
Jane Roessner, PhD
Chinatown Health Clinic
Writer
Institute for Healthcare Improvement
Frank Vinicor, MD, MPH
Todd Ruppar, RN, BSN
Director, Division of Diabetes Translation
Centers for Disease Control and Prevention
Community Health Nurse
Family Care Health Centers
Arcadio Viveros
Ardyce Saunders-Ridolfo, RN
Executive Director
Salud Para La Gente, Inc.
Wendy Melendrez, ARRT
Health Disparities Collaborative Coordinator
National Health Care for the Homeless
Tammy Walker
Quality Improvement Coordinator
Ben Archer Health Center
Marie Schall, MA
Teaching and Educational Specialist
Prospect Associates
Theresa Mendez
Collaborative Director
Institute for Healthcare Improvement
Doris Walzak, MD
Diabetes Coordinator
Mariposa Community Health Center
Cory Sevin, RN, MSN
Clinical Director
Columbus Neighborhood Health Center, Inc.
Regina Olasin, DO, FACP
Vice President
Clinica Campesina
Vivian Whitely, RN, CDFS
Medical Director
Laurel Health System
Charles W. Shafer, MD
Clinical Coordinator
Stewart Webster Rural HC, Inc.
John McFarland, DDS
President
National Network for Oral Health Access
Kathy McNamara
Assistant Director of Clinical Affairs
National Association of Community
Health Centers
Clinical Director
Sioux River Valley Community Health Center
DIABETES TRAINING MANUAL
3
Diabetes
The Challenge
Diabetes is a complex, serious, and increasingly common disease. It is the most frequent
cause of blindness among working-age adults; the leading cause of nontraumatic lower
extremity amputation and end-stage renal disease; and a principal cause of congenital
malformations, perinatal mortality, premature mortality, and disability. Persons with diabetes are at increased risk for stroke, ischemic heart disease, peripheral vascular
disease, and neuropathy.
< 4%
4 – 6%
> 6%
The Increasing Prevalence of Diabetes Among Adults
1990
1993–1994
Diabetes is a costly disease—not only in terms of the economic burden it imposes on
society, but also in terms of the human suffering imposed by the disease and its complications. Moreover, the burden of diabetes and its complications disproportionately affects
minority populations and the elderly, and is likely to increase as minority populations
grow and the U.S. population ages. Thus, diabetes poses an enormous public health challenge in America.
1999
Source: CDC
DIABETES TRAINING MANUAL
4
Diabetes: The Challenge (continued)
Diabetes: The Facts
➤ 15.7 million people have diabetes:
10.3 million diagnosed
(= a sixfold increase over the past
40 years)
5.4 million undiagnosed
➤ 798,000 new cases diagnosed per year
➤ 7th leading cause of death in the U.S.
➤ Cost (United States, 1997):
Total costs: $98 billion
Direct medical costs: $44 billion
Indirect costs: $54 billion (disability, work
loss, premature mortality)
Diabetes Disproportionately Affects
Minority Populations
➤ African Americans
African Americans are 1.7 times more
likely to have Type 2 diabetes than the general population. An estimated 2.3 million
African Americans, or 10.8%, have diabetes. 25% of African Americans between
the ages of 65 and 74 have diabetes, and
one in four African American women over
55 has diabetes.
➤ Latinos
Latinos are almost twice as likely to have
Type 2 diabetes. For example, diabetes
affects 1.2 million or 10.6% of the Mexican
American population.
➤ Native Americans
Overall prevalence of Type 2 diabetes in
Native Americans is 12.2%, compared to
5.2% of the general population. In some
tribes, 50% of the population has diabetes.
Complications of Diabetes
➤ Blindness
Diabetes is the leading cause of new cases
of blindness in adults ages 20 to 74 years.
➤ Kidney failure
Diabetes is the leading cause of end-stage
(chronic, irreversible) kidney disease.
➤ Amputations
Diabetes is the leading cause of lowerextremity amputations not related to
injury.
➤ Cardiovascular disease
People with diabetes are 2 to 4 times more
likely to develop heart disease or stroke
than people without diabetes.
Sources
➤ American Diabetes Association
(ADA) website:
www.diabetes.org/ADA/facts.asp
➤ “Diabetes: A Serious Public Health
Problem. At-a-Glance 2000.” Centers
for Disease Control and Prevention,
U.S. Department of Health and Human
Services.
DIABETES TRAINING MANUAL
5
Diabetes
The Solution
Although the challenge is formidable, we do
know what good diabetes care looks like and
we are continually increasing our knowledge
about good diabetes care. The scientific literature, centers of excellence in diabetes care, and
the experience of hundreds of health centers
are consistent in pointing to common themes
in excellent diabetes care—themes that are
applicable to a wide range of chronic diseases.
The Care Model outlines all of the key elements of a system of excellent care for people
with chronic illness. Hundreds of health centers have already begun putting such a system
of care in place, and they have begun to see
significant improvement in the health of those
they serve, often within a matter of months.
“You actually have
the opportunity to
demonstrate best
practice models and
as a result, you can
present this to companies, industries,
and legislators to
show that this actually works.”
Janice Bacon, MD
G.A. Carmichael
Family Health Center
Canton, Mississippi
“The quality of care,
the follow-up, the
educational processes involved with this
program, there’s
nothing that’s going
to replace that and
most important is
the clients’ involvement in their care.
When you get someone to buy into helping manage their
own care it really has a more significant outcome in
terms of how dedicated they’ll be to following through
on the program. If they know they have a good support system, of course they can do this. It would be
foolhardy not to try.”
Gladys Johnson
Diabetes Patient
Lafayette, Colorado
The people who work in the health centers—
senior leaders, physicians, nurses, front-line
staff—and the people they serve describe the
benefits best:
“I’m very encouraged how a community health center
with relatively limited resources can show such great
improvement in our patient outcomes.”
Eric Boysen, MD
Clinica Campesina
Lafayette, Colorado
DIABETES TRAINING MANUAL
6
Diabetes
Care Model Checklist
Self-Management
(pages 8 –14)
Decision Support
(pages 15–22)
Use diabetes selfmanagement tools that
are based on evidence
of effectiveness.
Embed evidencebased guidelines in the
care delivery system.
Set and document
self-management goals
collaboratively with
patients.
Train providers on
how to help patients
with self-management
goals.
Follow up and monitor self-management
goals.
Use group visits to
support self-management.
Tap community
resources to achieve selfmanagement goals.
Establish linkages
with key specialists to
assure that primary care
providers have access
to expert support.
Provide skill-oriented
interactive training programs for all staff in
support of chronic illness improvement.
Educate patients
about guidelines.
Clinical Information
System (pages 23–34)
Establish a registry.
Develop processes
for use of the registry,
including designating
personnel to enter data,
assure data integrity,
and maintain the
registry.
Use the registry to
generate reminders and
care-planning tools for
individual patients.
Use the registry to
provide feedback to care
team and leaders.
Delivery System
Design (pages 35– 40)
Organization of Health
Care (pages 41– 48)
Community
(pages 49–57)
Use the registry
to proactively review
care and plan visits.
Make improving
chronic care a part of
the organization’s vision,
mission, goals, performance improvement, and
business plans.
Establish linkages
with organizations to
develop support programs and policies.
Assign roles, duties,
and tasks for planned
visits to a multidisciplinary care team. Use
cross-training to expand
staff capability.
Use planned visits
in individual and group
settings.
Make designated staff
responsible for followup by various methods,
including outreach
workers, telephone calls,
and home visits.
Use promotoras
and community health
worker programs for
outreach.
Make sure senior
leaders and staff visibly
support and promote
the effort to improve
chronic care.
Assign day-to-day
leadership for continued
clinical improvement.
Integrate
Collaborative models
into the Quality
Improvement program.
Link to community
resources for defrayed
medication costs, education, and materials.
Encourage participation in community
education classes and
support groups.
Raise community
awareness through
networking, outreach,
and education.
Provide a list of
community resources
to patients, families,
and staff.
DIABETES TRAINING MANUAL
7
Self-Management
Patients with diabetes need support, as well as information, to become effective
managers of their own health. In order to meet these needs, it is essential for them to
have the following:
• Basic information about diabetes
• Understanding of and assistance with self-management skill building
• Ongoing support from members of the practice team, family, friends, and community
Providers need to be sensitive to the role that families, caregivers, and communities play
in different cultures. Better patient outcomes are achieved through use of evidence-based
techniques that emphasize patient activation or empowerment, collaborative goal setting,
and problem-solving skills. The provider team can use standardized assessments of
patient self-management needs and activities to enhance its ability to support patients.
These assessments include questions about self-management knowledge, skills, confidence, supports, and barriers.
Changes for Improving Self-Management
➤ Use diabetes self-management tools that are based on evidence of effectiveness.
➤ Set and document self-management goals collaboratively with patients.
➤ Train providers on how to help patients with self-management goals.
➤ Follow up and monitor self-management goals.
➤ Use group visits to support self-management.
➤ Tap community resources to achieve self-management goals. (See Community.)
CASE STUDY
Community Health Care
Davenport, Iowa
At the end of April 2000, a Physician Assistant (PA)
saw a patient at a Salvation Army Adult Rehab Center,
who presented with a blister on his left great toe. Two
weeks later, when the blister turned into an ulcer, he
was diagnosed with Type 2 Diabetes. On May 11, his
HbA1c was 13.6.
The PA spent a lot of time educating the man about
diabetes, diet, and exercise. The patient also met with
the dietician. Even after all this, he still did not seem
to understand the importance of diet and exercise in
controlling his diabetes: he presented for follow-up with
very high blood sugar, as a result of just having eaten
ice cream and cookies!
The PA encouraged him to attend a Diabetes Group Visit
on June 16. After the education and group discussion,
he finally understood the connection between his foot
ulcer, his diabetes, and self-management of his diet and
exercise plan. Since then, he has been actively involved
in setting goals for himself in collaboration with the health
care team.
The patient now returns for follow-up regularly. His blood
sugars have greatly improved. On August 31, 2000, his
HbA1c was 6.7, and on December 8 of that year it was
6.5. He remains at the Salvation Army Adult Rehab Center,
and is making smart choices about the food he eats. He
no longer chooses cookies and ice cream as a snack!
DIABETES TRAINING MANUAL
8
Self-Management
➤Use diabetes self-management tools that are based on evidence of effectiveness.
Steps
1
2
Tools and Resources
Identify high-quality patient education
materials.
Review materials for reading level and
cultural appropriateness. Determine if different
versions — languages, literacy levels — are
necessary to serve patients.
3
Review materials with the care team.
4
Test materials with a few patients and revise
as necessary.
5
Make materials available to patients, families,
and providers by placing them in examining
rooms and waiting rooms.
6
Tips
Be selective and keep materials brief. Include
materials with larger print.
American Diabetes Association
www.diabetes.org
State-Based Diabetes Control Program
www.cdc.gov/diabetes/states/index.htm
Work with lay health promotoras in the
community to select and review materials.
American Association of Diabetes Educators
www.aadenet.org
National Diabetes Education Program
www.cdc.gov/diabetes/projects/ndeps.htm
Stoplight Tool for HbA1c and
Blood Sugar Targets
Take Charge of Your Diabetes,
for Patients
www.cdc.gov/diabetes/pubs/pdf/tctd.pdf
Remove outdated educational materials from
the clinic.
Coordinate patient education with the center’s
care guidelines.
Share materials with pharmacies, faith-based
organizations, and community groups.
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
9
Self-Management
➤Set and document self-management goals collaboratively with patients.
Steps
1
Identify self-management tools, including
the following:
• An action plan that includes goals and
describes behavior (e.g., increasing activity
by walking 15 minutes 3 times per week)
• A review of the patient’s personal barriers
(e.g., too busy to exercise)
• Steps to overcome barriers
• The patient’s confidence level (e.g., on a
scale of 1 to 10, how confident are you
that you can meet your goals?)
• A follow-up plan
2
Review the tool with the multidisciplinary
team, including all those who will be involved
in its use—physicians, nurses, volunteers,
promotoras, etc.
3
Test the tool with a few patients and revise as
indicated. Retest with additional patients and
different populations.
Tools and Resources
Self-Management Support Tool
Diabetes Self-Management Goal Setting
(English and Spanish)
Diabetes Goal Contract
(English and Spanish)
Dental Self-Management Tool
Turning Patient Education into
Self-Management, Training Instructions
for Providers
Chronic Disease Self-Management Program
(CDSMP)
www.stanford.edu/group/perc/cdsmp.html
Tips
Make sure staff are comfortable with the
self-management philosophy and trained in
behavioral techniques to support patients.
Train lay workers to set goals with patients.
Create a system to communicate goal changes
with other providers caring for patients
(pharmacy, nursing, lay community workers,
etc.) so that they can reinforce them. For
example, write new goals (e.g., “walk 15 minutes 3 times per week”) on a prescription pad
and give to patients to show to other providers.
Develop a process and train providers so that
the self-management process can fit in the
15- to 20-minute visit, if necessary. It does not
require a long session.
Work with patients to define goals.
Don’t prescribe goals or use checklists.
Include family and caregivers in setting goals.
Use groups for patient goal setting.
4
Establish and/or review goals with patients as
part of the planned visit and follow-up.
5
Assess patients’ skill, understanding, and
confidence in managing their disease.
6
Give patients a copy of goals, and place a copy
in the chart.
Diabetes Patient Questionnaire
Have medical assistants ask patients about
goals when taking vitals.
Have providers review goals with patients briefly.
Assign staff to arrange follow-up with patients.
Document goal setting in the registry. Include
some specifics of the goal and the date(s).
DIABETES TRAINING MANUAL
10
Self-Management
➤Train providers and other key staff on how to help patients with self-management goals.
Steps
1
Select a self-management curriculum that has
been tested and found effective.
2
Train everyone on the health care team
(including volunteers and promotoras) using
a skilled trainer, if possible.
Tools and Resources
Article on a motivational intervention to
improve care in Type 2 diabetes
fampract.oupjournals.org/cgi/reprint/15/3/229.pdf
Bayer Institute for Health Care, Patient
Communication Training
www.bayerinstitute.org
Health Professional Training and Patient
Education in Diabetes (University of Michigan
Diabetes Education Center)
Tips
The best self-management approaches are
those that are patient-oriented and assist
patients with the disease as they live with it,
as opposed to “shoving information at them”
from a curriculum. This is a change from
previous practice around diabetes education.
Make training as interactive as possible.
Include role-play and case studies.
Have “homework” and in-class assignments.
www.med.umich.edu/mdrtc
3
4
5
Define tasks and roles—e.g., who will set the
action plan, who will do follow-up, who will
fill out the assessment form—and assign them.
Self-Management Checklist
(to Enhance Your Self-Management)
Self-Management Coordination Matrix
Let self-management coaches self-select. Those
who are comfortable with the self-management
approach are the most effective coaches.
Test the self-management tool with
one provider and team working with
several patients.
Start on a small scale.
Provide follow-up education for providers.
Review the self-management tool and gradually
add layers of competence and complexity.
Educate providers about the importance of
not “lecturing” their patients.
Let patient concerns lead discussions.
Think incrementally about behavior change.
Encourage patients to take small steps and
build confidence through success.
DIABETES TRAINING MANUAL
11
Self-Management
➤Follow up and monitor self-management goals.
Steps
1
Train staff for follow-up.
2
Test having different staff or volunteers do
follow-up.
3
Schedule follow-up based on dates in the
action plan.
4
Test follow-up mechanisms (calendar, registry,
tickler file) and scripts.
5
Include problem solving (a technique to
help patients identify problems and develop
solutions) in follow-up.
Tools and Resources
Tips
Don’t skip follow-up; patients will think you
don’t care.
Make sure patients determine the follow-up
date and method. Follow-up can be by phone,
email, fax, home visit, clinic visit, etc.
Use trained, culturally competent lay people
for follow-up.
Chronic Disease Self-Management Program
(CDSMP)
www.stanford.edu/group/perc/cdsmp.html
DIABETES TRAINING MANUAL
12
Self-Management
➤Use group visits to support self-management.
Steps
Tools and Resources
1
Identify the type of group visit (support group,
educational group, etc.).
Turning Patient Education into
Self-Management, Train-the-Trainer
Instructions for Providers
2
Identify a group to focus on (e.g., Hispanic
population, homeless, newly diagnosed).
Group Visit Agenda
Tips
Assess cultural/ethnic needs and identify appropriate methods/materials for patient education.
Don’t confuse this type of group with a group
visit that includes the physician and medical
care (described in Delivery System Design).
Let the group determine the content of
sessions. Leaders can monitor the content to
assure that critical information is covered.
3
Identify and train the facilitator.
4
Take care of logistics (space, staffing needs,
billing requirements).
Contact health centers that have been
conducting group visits for “lessons learned”
about logistics of scheduling, rooms, etc.
5
Publicize group visits through an appropriate
communication channel.
Make reminder calls.
Provide a meal.
Use lay leaders.
Anticipate patient’s need for transportation
and child care.
DIABETES TRAINING MANUAL
13
Self-Management
➤Tap community resources to achieve self-management goals. (See Community.)
Steps
1
Tools and Resources
Identify resources in the community that
would help in meeting self-management goals,
such as exercise programs and meal programs.
Tips
Consider senior centers, faith-based organizations, and public housing. Draw on the
community network.
Think big: local, state, federal.
2
Educate patients and staff on local resources.
See list of tools in Community section.
Provide resource list to clients.
DIABETES TRAINING MANUAL
14
Decision Support
Effective chronic illness management programs follow explicit guidelines or protocols,
preferably evidence-based guidelines. Reminders, provider education, appropriate
input, collaborative support from relevant medical specialties, and patient participation
support their implementation.
Changes for Improving Decision Support
➤ Embed evidence-based guidelines in the care delivery system.
➤ Establish linkages with key specialists to assure that primary care providers have
access to expert support.
➤ Provide skill-oriented interactive training programs for all staff in support of chronic
illness improvement.
➤ Educate patients about guidelines. (See Self-Management.)
CASE STUDY
Johnson County Community Health Care Systems
Wrightsville, Georgia
Community Health Care Systems is a small, rural health
center serving a low-literacy population. The providers
received training on the use of the latest evidence-based
guidelines. They used the guidelines to create a protocol
format and a flow sheet that serves as a checklist
reminder system for comprehensive diabetes care.
Perhaps the most important “prompt” the providers have
created is the patients who come to them. The patients
have been educated in the guidelines through diabetes
education displays placed in the waiting room, a diabetes
bulletin board in the examining room, and efforts and education to have the patients “Take Control” of their diabetes.
The providers now have a number of prompts to follow
the guidelines: the education they receive on a regular
basis, the flow sheet that serves as a reminder and, most
important, the well-informed, activated patients who are
enthusiastic, informed participants in their own care.
DIABETES TRAINING MANUAL
15
Decision Support
➤Embed evidence-based guidelines in the care delivery system.
1
Steps
Tools and Resources
Tips
Identify existing guidelines.
Websites with information on evidencebased medicine:
Don’t reinvent the wheel! Obtain existing
guidelines from the National Guideline
Clearinghouse or your state Diabetes Control
Program, or use standards from reputable
organizations such as the American Diabetes
Association (ADA).
Examples:
• Glycemic control for people with diabetes:
HbA1c (%) goal <7
• Lab evaluation of GHb: quarterly if treatment changes or patient is not meeting goals;
or two times a year if the patient is stable
The Unit for Evidence-Based Practice
and Policy
www.ucl.ac.uk/openlearning/uebpp/uebpp.htm
Centre for Evidence-Based Medicine
cebm.jr2.ox.ac.uk
Netting the Evidence
www.shef.ac.uk/~scharr/ir/netting
New Zealand Guidelines Group
www.nzgg.org.nz
National Guideline Clearinghouse
Involve a provider champion or your Medical
Director in selecting guidelines, but be certain
to obtain consensus on guidelines among the
providers you expect to implement them.
Focus initial effort on guidelines that are easily
agreed upon. Don’t get sidetracked by controversial topics: work on those guidelines later.
Mix and match guidelines as needed.
www.guideline.gov
Cochrane Reviews
www.cochrane.org/cochrane/revabstr/
mainindex.htm
Trip Database
www.tripdatabase.com
Clinical Evidence for Providers
[email protected] or 877-485-8074
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
16
Decision Support
➤Embed evidence-based guidelines in the care delivery system. (continued)
Steps
2
Review guidelines and select the best one(s)
for your clinical setting. Make sure they are
based on the best medical evidence.
3
Teach providers the basics of evidence-based
medicine and guideline review.
4
Have providers review and discuss guidelines
to develop consensus.
Tools and Resources
Evaluating a Guideline
Tips
Set clear expectations and timelines for guideline development, review, and adoption.
If committee review is required for accepting
a guideline, have the committee consider only
the evidence-based guideline.
Include evidence summaries that accompany
good guidelines to facilitate discussion.
Send a physician to a CME session on evidence-based medicine.
To get buy-in from influential naysayers,
involve them in the process.
Remove barriers to guideline implementation,
such as unavailability of needed vaccines,
slow turnaround time for lab results, inertia.
5
Customize guidelines for the clinic, within
the boundaries of the evidence.
6
Use a standardized assessment to diagnose
and determine disease control and risk for
complications (heart, eyes, kidneys, etc.) to
guide management for all patients.
7
Consider conducting a baseline chart audit
to benchmark your current practice against
agreed-upon guidelines. Agree before the
audit which patients to include (see Clinical
Information System for establishing a registry).
Do NOT omit charts because a randomly
selected chart is not that of a “typical” patient.
Don’t get mired down in complex algorithms
or standards of care.
Talk to other clinics that have already
customized guidelines to get the fastest process
in place.
Keep chart abstraction simple and quick;
collect only the data that are needed.
Diabetes Care Chart Audit
Have providers abstract a random sample of
their own charts. This helps them discover the
gap between what they know is good practice
and what they actually do. Try a “lunch and
learn” session to achieve this.
Try to integrate the chart audit with development of the registry. Talk to other clinics that
have already customized guidelines.
DIABETES TRAINING MANUAL
17
Decision Support
➤Embed evidence-based guidelines in the care delivery system. (continued)
Steps
8
9
Use flow sheets, pathways, or checklists
to embed guidelines into daily practice.
The guidelines include triggers for care.
Link guidelines to the information system
to provide prompts.
Tools and Resources
Diabetes Flow Sheet
Patient Encounter Form
Diabetes Protocol Checklist
Tips
The patient encounter form may also be
known as a visit note, flow sheet, treatment
planning form, order entry form, etc.
Make it as hard as possible to ignore the
guideline. Make it easier to do the right thing
(e.g., check a box instead of having to write
out a lot of information).
Make it efficient to follow guidelines. Physicians
will be more likely to use them if they save time.
Make it hard to forget to follow guidelines:
work with the lab to develop staged testing
protocols (e.g., automatic microalbumin
measurement when an annual screening U/A
is negative for protein to avoid recall of
patient/resubmission of urine).
Ask teams that are already practicing evidencebased medicine to spread the word. If a team is
not practicing this way, have them visit another
clinic that is.
10
Review and update guidelines for care
regularly (at least yearly).
Why Don’t Physicians Follow Clinical Practice
Guidelines? A Framework for Improvement
11
Remove barriers identified with previous
guidelines.
Michael D. Cabana; Cynthia S. Rand; Neil
R. Powe; Albert W. Wu; Modena H. Wilson;
Paul-André C. Abboud; Haya R. Rubin. JAMA.
1999;282:1458-1465.
Think about why guideline implementation
is not working:
• Lack of awareness
• Lack of agreement
• External factors (time, money, resource
availability)
• Inertia
Discuss which of these factors is playing
a role. You may have to address multiple issues
simultaneously.
DIABETES TRAINING MANUAL
18
Decision Support
➤Establish linkages with key specialists to assure that primary care providers
have access to expert support.
Steps
1
Find specialists who will treat your patients
and support your improvement efforts.
2
Review guidelines with specialists to get their
input and buy-in.
Tools and Resources
Tips
Seek out institutions with a similar public
health mission or teaching institutions to
identify specialists to work with. Teaching hospitals may agree to have residents or fellows
(cardiology, optometry, podiatry, dental, etc.)
rotate through your clinic, who then can help
link to hospital for needed procedures.
Ask specialists to be part of the team.
Include specialists in the guideline development
process.
3
Work with specialists to define appropriate
patients for referral, based on the guidelines.
4
Work with specialists to clarify the approach
to follow-up (i.e., the process for getting information to the primary care provider after the
specialist sees the patient).
5
6
Develop a mechanism to track the following:
• Referral made
• Specialist saw patient
• Specialist’s letter received by primary care
provider
• Patient returned to primary care provider
Streamline the process for communication
back and forth (e.g., fax-back forms, email,
telephone conferences, telemedicine sites).
The easier it is, the more likely it will happen.
Use the same specialists whenever possible.
Have senior leadership make follow-up
between specialty and primary care provider
a clear expectation at both locations.
Fax-back Form
Patient Encounter Form
Designate a specific person to do the tracking
and develop a standardized process to track
referrals and information from the specialist.
If possible, use the registry to track this information. Audit 5 to 6 patients periodically to
see if the process is working.
Use joint visits with specialists or
direct phone consultation and other innovative
primary care/specialist relationships.
DIABETES TRAINING MANUAL
19
Decision Support
➤Provide skill-oriented interactive training programs for all staff in support of chronic illness improvement.
Steps
Tools and Resources
Tips
1
Evaluate educational needs of staff.
Keep surveys simple and easy to complete.
2
Schedule in-services routinely and
opportunistically.
Use multiple media for training (e.g., memos,
“commercials” during in-services, sit-down
in-services).
Make use of existing means of reaching staff.
Consider pop quizzes.
Make sure CMEs are consistent with your
care guidelines.
3
Use an expert, mentor, or specialist for
education.
Choose a person who believes in primary care
as the basis for delivery of good chronic care.
Rotate experts: use different disciplines
(pharmacy, nursing, physical therapy, patient
education, etc.).
4
Use care management conferences to encourage
guideline-based practice:
• Develop a multidisciplinary case review/care
management team.
• Determine the frequency of case reviews.
• Decide how case review information will
be used:
- To make changes in care delivery
- To educate providers
- To educate patients
Keep meetings brief and purposeful.
Use lessons from individual patients for
teaching.
Make sure that “Next Steps” are part of
the agenda.
Review the care management conference
process periodically to make sure it is still
meeting a need. Make sure it doesn’t become
time consuming.
DIABETES TRAINING MANUAL
20
Decision Support
➤Educate patients about guidelines. (See Self-Management.)
Steps
1
Develop “patient-friendly” guideline handouts
or wallet cards and distribute them to patients.
Tools and Resources
Wallet Card
www.doh.wa.gov/ndep/wallet.htm
Tips
Survey patients about their knowledge of
disease processes.
Patient Guide for Diabetes Management
Be sensitive to the cultural environment of
the patient and family.
National Institute for Diabetes & Digestive
& Kidney Disease
Post information about guidelines in the clinic
lobby and other public places.
www.niddk.nih.gov/health/diabetes/pubs/
complications/teeth/teeth.com
Indian Health Service,
Patient Education Materials
www.ihs.gov/medicalprograms/diabetes
2
3
Have providers reinforce patient expectations:
clarify the patient’s role in making sure recommended tests and exams are completed according to the guideline.
Hemoglobin A1c and Blood Sugar Targets
Give patients charts of their HbA1c values,
LDL, etc.
Patient Tips for Good Control
(English and Spanish)
Mail the patients information about good
control to bring with them to their visits.
Include “patient expectations” as part of
all support groups, health fairs, and public
presentations.
Evidence-Based Health Care Guideline
Implementation Study
Provide a script for the providers to explain
patient expectations.
www.qmnetwork.org
Make follow-up calls (using the registry) to
see if the patient followed through.
DIABETES TRAINING MANUAL
21
Decision Support
Materials for People with Diabetes
The following resources are available at
ndep.nih.gov/materials/puborder/resource.htm#people
Take Care of Your Feet for a Lifetime
(English and Spanish)
If You Have Diabetes, Know Your Blood
Sugar Numbers (English and Spanish)
7 Principles for Controlling Your Diabetes
for Life (English and Spanish)
This illustrated patient booklet
provides step-by-step instructions
for proper foot care. Includes a
tear-off reminder card and a patient
“To Do” list.
This reproducible, black-and-white
patient education brochure provides
information on measuring blood
sugar levels using the hemoglobin A1c
test and the finger-stick test (with a
blood glucose monitor) (published
8/98, updated 3/00).
This easy-to-read brochure for people
with diabetes describes the essential
components of quality diabetes care in
a checklist form.
Control Your Diabetes. For Life.
Tips for Feeling Better and Staying Healthy
(English and Spanish)
Patient education materials designed
for the Native American audience, which
may be useful for other populations
This two-color patient education booklet provides an action plan for diabetes
control that includes tips on knowing
blood sugar levels, reaching blood sugar
goals, and maintaining blood sugar
control (published 8/98).
DIABETES TRAINING MANUAL
22
Clinical Information System
To provide good care for people with chronic illness, clinicians need access to timely,
clinically relevant information about each patient in the practice, as well as the
population of patients as a whole. Useful information includes recommended services
(e.g., foot exams), key outcome measures (e.g., HbA1c, LDL), medications, and
patient contact information.
A system that records all relevant patient care information is often referred to as a
“registry.” Providers can use the registry to record critical elements of the care plan,
produce quick care summaries at the time of a visit, and enter data to alter the care
plan as needed. A patient registry is most useful when patient data is available to
the provider at the point of the patient visit when decision support is most needed.
The registry can remind providers of needed services, represent feedback on performance
of both the clinic and the provider, and serve as a source of up-to-date information for
encounters. Health care teams can also use the registry to contact groups of patients with
similar care needs and deliver planned care and educational sessions.
Changes for Improving Clinical Information System
➤ Establish a registry.
➤ Develop processes for use of the registry, including designating personnel to enter
data, assure data integrity, and maintain the registry.
➤ Use the registry to generate reminders and care-planning tools for
individual patients.
➤ Use the registry to provide feedback to care team and leaders.
CASE STUDY
Lawndale Christian Health Center
Chicago, Illinois
Lawndale Christian Health Center made a commitment to
enter data on all of their diabetic patients (approximately
1,000) into an electronic registry. The intention was to
use the registry to present graphs to patients, demonstrating
their progress with average HbA1c at each visit; generate
monthly reports for individual providers, senior leadership,
and the Board of Directors; create an effective mechanism
to communicate with outside funders and agencies
about the center’s diabetes population; and respond to
queries regarding patients at risk or in need of specific
tests and follow-up.
Initially, the physician champion entered all data herself,
but as the process spread to more patients and providers,
the team realized that they needed more help—both for
data entry and training additional staff. They approached
the receptionist to ask if she could assist with lab data
entry. Not only was she glad to help, but also she took
pride in the fact that she was involved in this important
collaboration to improve the health of the health center’s
diabetic patients!
This fervor has now spread to all of the nursing assistants,
who are trained in data entry for new diabetic patients and
printing off the registry form for patient visits. The registry
is now available on all computers at Lawndale via a network, and it has been promoted as a means to improve
adherence to standards.
DIABETES TRAINING MANUAL
23
Clinical Information System
Creating an Electronic Registry of Your Patients
Identifying and keeping track of the patient population is
the backbone to delivering population-based care. A registry
is a mechanism for keeping all pertinent information about
a specific group of patients at your fingertips. The Bureau of
Primary Health Care, along with the Centers for Disease
Control, has supported the development of several diseasespecific electronic registries (Microsoft Access-based), which
are available to all health centers free of charge: DEMS
(Diabetes Electronic Management System) for diabetes and
CVDEMS for cardiovascular and diabetes combined. Work
is also progressing on a more generalized registry; check
www.healthdisparities.net for updates.
There are hardware and software considerations for using
the electronic registry. For instance, CVDEMS requires that
a clinic have one working copy of the Microsoft Access program (Access 97 or Access 2000), a printer (preferably color),
and at least 32 MB RAM and about 20 MB of free space
on the hard drive. See the Computer Assessment Tool at
www.healthdisparities.net for a full list of hardware and software requirements for the use of CVDEMS.
Integration of an electronic registry into your center’s operations will require a team approach represented by key personnel: physicians, nurses, medical records, front-line support staff
(clerical, medical assistants), information systems (if available),
and administration. Please refer to the list of questions in the
Registry Assessment Tool at www.healthdisparities.net for the
types of resource and redesign issues you will face.
DIABETES TRAINING MANUAL
24
Clinical Information System
➤Establish a registry.
Steps
1
Tools and Resources
Choose or develop an electronic or manual
registry.
Electronic Method: Choose a computer application that allows for flexible data handling
and reporting. Make sure the application
makes it easy to get patient information into
and out of the system. It should also be easy
to transfer information to and from other
systems (e.g., billing, lab, appointments), or
even have a direct interface with these systems.
Electronic Registry
Constructing a Registry
Registry Assessment Tool
Computer Assessment Tool
Tips
Choose software that can capture needed
data from existing computer systems and is
within budget.
Visit a center with a well-implemented
patient registry.
Keep manual data entry to a minimum.
Whenever possible, transfer information
electronically from systems like appointments
and billing.
Remember that a registry is NOT an automated medical record. A registry is a repository
of essential care elements based on a care
guideline.
Manual Method: Develop a card file or
notebook that can be used to track patient
information.
Identify team members with good computer
skills to manage the registry and train others
how to use it.
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
25
Clinical Information System
➤Establish a registry. (continued)
Steps
2
Decide on what data to include in the
registry, based on the essential elements of
good diabetes care. (See Decision Support.)
Tools and Resources
Chart Abstraction Form
Diabetes Care Chart Audit
Definition of Homelessness
Track II: National Tracking and Referral
Project for Migrating Patients with Diabetes
Migrant Clinicians Network
www.migrantclinician.org
Health Care for the Homeless
Clinicians’ Network
615-226-2292
[email protected]
www.nhchc.org
Tips
Use precise and consistent definitions for each
key measure. Make sure you capture information required by accrediting bodies or managed
care organizations. For example, define a
retinal eye exam the same way for the provider
as you would for HEDIS.
Start small, but make sure the system lets you
add new data elements as guidelines change
and providers become more sophisticated.
Don’t overwhelm people with too much information at first.
Don’t forget to include the following, which
are cultural indicators that can help you reach
migrant and homeless patients and other
underserved populations:
• Ethnicity
• Language
• Insurance coverage
• Patient mobility
Contact the Bureau of Primary Health Care’s
Health Care for the Homeless program and
the Migrant Clinicians Network to obtain
information on items to include for mobile
populations.
Make sure that your registry will also be
useful for reports:
• Quality Improvement projects
• Provider feedback
• Grant applications
• Financial management
• HEDIS
• Special populations
DIABETES TRAINING MANUAL
26
Clinical Information System
➤Establish a registry. (continued)
Steps
3
4
Document how you established the data
elements on a template, so that new staff
can replicate the process.
Build the registry by using an existing information system to identify the majority of patients
with diabetes. For example, add names from
billing data or the ICD9 250.xx list for the last
calendar year. Add names as new patients join
the clinic.
Tools and Resources
Sample Registry Report
Tips
Keep the template simple and easy to use.
Use the tool in the CVDEMS registry to import
DEMS data.
Many of the existing systems (especially
Excel- and Access-based) also have easy-to-use
data import features.
Try to include all diabetic patients, even if
the practice doesn’t recognize or claim them.
Most providers dramatically underestimate
the number of patients with diabetes in their
patient population.
Work with information systems experts to
develop ways to update the registry monthly,
based on billing, pharmacy, and lab data.
5
Share the list of diabetes patients with the
practice team to eliminate miscodes. Have team
“clean” the list by noting patients who are not
diabetic, who have long since moved out of the
area, or who have died. Some groups perform
a chart audit to clean the registry.
Review the registry for accuracy. If too many
people with diabetes are missed, providers
won’t trust the registry.
In many cases, it takes an actual patient visit to
determine if someone should not be in the registry. However, most health centers have found
most inaccuracies through a chart audit.
Flag gestational diabetes as appropriate.
DIABETES TRAINING MANUAL
27
Clinical Information System
➤Establish a registry. (continued)
Steps
6
Document the process of identifying patients
as “inactive.”
Tools and Resources
Tips
Use the following definition: patients with
diabetes (Type 1 and Type 2) who were continuously enrolled during the year and who
have at least one visit to the clinic within the
past calendar year are considered clinic patients
unless there is documentation that the patient
has transferred to another practice or has
moved from the area. In addition, clinics with
managed care plans should try to include
patients with diabetes who have no documented
medical visit to the clinic, and who have been
assigned to the clinic for 12 months, with no
more than a 45-day drop in coverage. ICD-9
code of 250.00 –250.99.
Tie the registry update process to standard
forms to be completed when a patient dies or
is removed from the clinic roster.
7
Use color dots to identify the medical records
of persons with diabetes.
Place a tab in chart, color-coded stickers,
and/or “Foot Exam” sticker to identify records
of persons with diabetes.
Ensure patient confidentiality. (Don’t write or
type “Diabetic” on the outside of the chart.)
DIABETES TRAINING MANUAL
28
Clinical Information System
➤Develop processes for use of the registry, including designating personnel to enter data,
assure data integrity, and maintain the registry.
Steps
1
Develop tools for collecting data. (Use computer programming to capture electronic data
when available.)
Tools and Resources
Tips
Use DEMS or CVDEMS Visit Note. Many
of the existing registries have Visit or
Encounter Notes that provide the focal point
for data collection.
If you’re not using DEMS or CVDEMS, use
a data collection sheet.
Include homeless/migrant status on the
data collection tool to identify an important
subpopulation.
2
3
Train people who will be collecting and entering data into the registry. Include test cases for
entering data.
Periodically have two team members enter
the same data and check on reliability.
Create a process for data entry. It is best to
enter data directly into the registry during the
visit. Even if this is not currently possible,
make sure the process is well described so that
it can eventually become part of people’s daily
work. Data entry and maintenance are part of
the center’s daily operations, not an “add-on”
task at the end of the day.
Ensure that the data entry person is given
time to enter data in “real time.” Enlist senior
leader’s support.
Periodically check registry data against your
data entry sheet.
Perform data entry on the day the data
becomes available.
Include clinic visits, lab work, outside visits,
tests, and education.
Look at your current data flow and minimize
handoffs.
Consider using trained volunteers to enter data.
Enter data at point of service if computers are
available in examining rooms.
DIABETES TRAINING MANUAL
29
Clinical Information System
➤ Develop processes for use of the registry, including designating personnel to enter data,
assure data integrity, and maintain the registry. (continued)
Steps
4
Schedule and produce reports.
Tools and Resources
Tips
Include reports for:
• Providers
• Managers
• Board of Directors
• Referral clerks
Enlist Risk Management support:
The identification of high-risk patients and
timely attention to standards of care can
be an important defense against lawsuits.
5
Ensure system security.
Use password protection.
Determine who has read/write access and
who decides about access.
Make sure computer terminals in public places
don’t violate confidentiality.
6
Make sure that people who need information
from the system can get it in a timely manner.
Design front-end “buttons” for one-touch
printing of reports and forms.
Use fast printers if possible.
7
Make sure staff are trained on data entry,
backup, and security procedures.
Make training on the system part of orientation for all staff.
Use an orientation checklist for consistency.
DIABETES TRAINING MANUAL
30
Clinical Information System
➤ Develop processes for use of the registry, including designating personnel to enter data,
assure data integrity, and maintain the registry. (continued)
Steps
8
Tools and Resources
Establish system backup.
Tips
Schedule and test backups.
Determine who is responsible for backup and
when/how frequently backups are done.
An example of an effective system backup plan…
Who will back up your data?
Jim will be in charge of backing up
the data.
When will you back up your data?
Jim will back up the data file every
Thursday afternoon at 2:30 p.m. during
his admin break.
Which method will you use to back up
your data?
Jim will add the data file to a zip file and
copy that zip file onto a floppy disk.
Where will you keep your backups?
Jim will put the disks in the disk holder
labeled “CVDEMS Backups,” which will be
kept in the medical records office. We will
keep 4 weeks of backups at any time in this
disk holder: the most recent backup (week 4),
the least recent backup (week 1) and the
second-to-the-least-recent backup (week 2).
Jim will put the second-to-the-most-recent
backup (week 3) in the secure filing cabinet
in the administration building.
DIABETES TRAINING MANUAL
31
Clinical Information System
➤Use the registry to generate reminders and care-planning tools for individual patients.
Steps
1
Use patient treatment record forms that include
services needed at time of visit. Before a visit,
print out current information from the registry.
Tools and Resources
Tips
Determine how to identify patients with
diabetes prior to a visit, and create a process
to ensure that the treatment record form is
on the chart in the examining room.
Determine if your appointment system has the
capability to flag patients with diabetes.
Flag charts to help identify patients with diabetes.
2
Use the registry periodically to generate lists
of patients who are missing a service or have
a service that is overdue.
Database queries might include the percentage
of patients with each of the following criteria:
• 2 HbA1c measurements in 1 year, at least 3
months apart
• Foot exams
• Retinal exams
• Renal screen and appropriate treatment
• HbA1c > 8
3
Use the registry to generate lists of high-risk
patients for specialized care and follow-up.
Create a protocol for which you are going to
follow up and how.
Use lists to send reminders by mail or make
follow-up phone calls. To protect patient
confidentiality, do NOT use postcards.
Use patient wallet cards to remind patients
what needs to be done, when.
Create a take-home patient summary sheet.
Create a protocol for which patients you are
going to follow up and how.
Database queries might include:
• Patients with BMI > 25
• Smokers
• Patients not seen in last year
• Patients with high-risk feet
• Patients with multiple co-morbidities
• Patients with HbA1c > 9
DIABETES TRAINING MANUAL
32
Clinical Information System
➤Use the registry to generate reminders and care-planning tools for individual patients. (continued)
Steps
4
Divide the population of diabetes patients into
categories (e.g., ethnicity, language, insurance,
needs/limits, homelessness) to identify special
needs.
Tools and Resources
Health Care for the Homeless
Clinicians’ Network
615-226-2292
[email protected]
www.nhchc.org
Tips
Alert community partners to keep you
updated on new ways to meet the needs of
these populations.
See ideas in “Care Model: Changes for Specific
Populations” section of this manual.
5
Decide how to handle patients with missing
services. Consider using planned visits, fitting
diabetes care into acute care visits, and group
visits. (See Delivery System Design.)
Have a team huddle at start of day to review
that day’s patients for missing services.
6
Use the registry to invite patients to health
fairs, informational meetings, etc.
Assign the role of keeping updated on community activities to a team member.
Create electronic links between registry and
mailing programs.
7
Use the registry to identify the under-insured
population to solicit for special services and
medical assistance programs.
Establish linkages to community wellness
programs for the poor.
Partner with existing community coalitions
to build linkages to other community-based
organizations.
DIABETES TRAINING MANUAL
33
Clinical Information System
➤Use the registry to provide feedback to care team and leaders.
Steps
Tools and Resources
Tips
1
Decide which elements or fields in the
registry, and which subgroups of patients,
to report on.
Keep it simple.
2
Develop a format for feedback.
Allow for formatting suggestions after first
draft, but don’t try to reach consensus across
all end-users.
Use feedback reports that are automated and
easy to produce.
Standardize reports across teams for easy
interpretation and comparison.
3
Decide who receives feedback and how often.
Send monthly reports to Board, senior leaders,
and team.
Show blind comparison data of other providers
to motivate providers.
Have managers evaluate and support outliers.
Incorporate CME with data feedback as a
decision support service to providers.
DIABETES TRAINING MANUAL
34
Delivery System Design
Effective management of chronic illness requires more than simply adding interventions
to an existing system focused on acute care. Rather, it necessitates basic changes in delivery system design. These changes require a shift of emphasis to “planned” visits instead
of acute visits. Effective management often requires expansion of staff member roles and
responsibilities. These changes include all professionals (e.g., nurses, health educators)
who have the knowledge and time to carry out the range of tasks required to manage
complex chronic conditions. Staff members also need timely access to key clinical data,
enough time to interact with patients, and regular, planned follow-up with patients.
Meeting these needs often requires innovation in the scheduling and organization of care,
such as group or individual planned visits.
Changes for Improving Delivery System Design
➤ Use the registry to proactively review care and plan visits.
(See Clinical Information System.)
➤ Assign roles, duties, and tasks for planned visits to a multidisciplinary care team.
Use cross-training to expand staff capability.
➤ Use planned visits in individual and group settings.
CASE STUDY
High Plains Community Health Center
Lamar, Colorado
There are some very satisfied patients and staff at High
Plains Community Health Center these days. The center
initiated a Diabetes Clinic in which the patient has a
planned encounter with the provider and a number of
other staff.
Some changes revealed the need to cross-train the staff
to perform multiple functions so that the patient is not
short-changed if there is illness or an emergency on the
part of one of the four staff who provide assessment and
care at the Diabetes Clinic.
The patient is prepared in advance with pre-ordered labs
and what to expect during the visit. The nursing staff
orders labs according to protocols, as well as performs foot
assessments and education, thereby freeing the provider
to spend more time with the patient on setting goals and
discussing problematic areas. The Diabetes Clinic is a
“4-in-1” visit, with the patient having a foot, dental, dietary,
and medical provider assessment.
➤ Make designated staff responsible for follow-up by various methods,
including outreach workers, telephone calls, and home visits.
➤ Use promotoras and community health worker programs for outreach.
DIABETES TRAINING MANUAL
35
Delivery System Design
➤Use the registry to proactively review care and plan visits. (See Clinical Information System.)
Steps
1
2
Tools and Resources
To institute proactive care, review the
registry to identify population-based needs
(e.g., eye and dental exams) and plan group
visits/mailings/fairs/reminders to patients
to meet those needs.
Use planned visits. The provider care team:
• Identifies diabetic patients coming in for an
appointment the next day.
• Looks at registry data and identifies needs on
flow sheet/visit note/encounter note.
• Plans visit, including who will draw labs,
make referrals, and do self-management
goals.
Tips
Use the reports from the registry that can
answer the many patient care-related questions
(e.g., “List all patients who have not had an
HbA1c in 6 months”).
Sample Registry Report
Conducting a Continuing Care Clinic:
Handbook for the Practice Team
Schedule regular staff time for population
review. Look for areas for improvement, e.g.,
smoking cessation, blood pressure control, and
foot exams.
Use daily huddles for staff to communicate
patient needs.
Use daily care team meetings to prepare for the
day’s planned visits.
Consider having patients come in a few days
before an appointment for blood draw so that
lab results are available at the time of the
appointment.
Consider “one-stop shopping” appointments
with multiple providers for patients with many
overdue needs.
3
Use care flow sheets, charting templates or
similar tools to guide care and follow-up.
(See Clinical Information System.)
Diabetes Flow Sheet
Use mail merge software for mailings/reminders.
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
36
Delivery System Design
➤Assign roles, duties, and tasks for planned visits to a multidisciplinary care team.
Use cross-training to expand staff capability.
Steps
Tools and Resources
1
Determine who has responsibility for each
step of the planned visit.
2
Obtain senior leader support for training staff
in new roles and tasks.
3
Identify who will do the training.
4
Identify resources, training material, and tools.
Training materials, e.g., Lower Extremity
Amputation Prevention (LEAP) Program
5
Offer opportunities for the staff member
being cross-trained to shadow or observe
the staff member doing the procedure
(e.g., foot exam).
bphc.hrsa.gov/leap/
6
Train providers, medical assistants, nurses (e.g.,
in LEAP exam, self-management goal-setting
and follow-up, phlebotomy), and periodically
check staff competency with tasks.
7
Use standing orders for referrals.
• Query registry monthly for all diabetes patients
due or overdue for eye or dental exam.
• Give list of due or overdue eye or dental
exams to designated referral person, who
then makes referral automatically from
monthly list of overdue exams, etc.
8
Use standing orders for labs.
• Develop standing orders for RN or dietician.
• Educate RN and dietician on use of
standing orders.
• Use registry to identify patients who need
labs and send letters to patients requesting
they get them.
Tips
Beware of relying on volunteers: they should
be under the supervision of a paid employee so
that if the volunteer is unable to do the task
(e.g., follow-up phone calls), the supervisor is
aware and can make other plans.
“Feet Can Last a Lifetime” Kit (2000),
National Diabetes Education Program
(includes ready-to-use exam forms,
patient education handouts, etc.)
ndep.nih.gov/materials/pubs/feet/feet.htm
Standing Orders
DIABETES TRAINING MANUAL
37
Delivery System Design
➤ Use planned visits in individual and group settings.
Steps
1
Obtain senior leadership support for planned
visits, especially to resolve potential reimbursement issues relating to group settings.
2
Block time for providers in advance.
3
Use registry to identify patients in need of visits.
4
Have promotoras, community health workers,
volunteers, or appointing staff call and schedule patients for visits.
5
Train staff in planned visit approach. A
planned visit should contain an assessment,
review of therapy, review of medical care,
self-management goals, problem solving,
and follow-up plan.
Tools and Resources
Have planned visits be part of the health
center’s stated philosophy of care.
ETHNIC: A Framework for Culturally
Competent Clinical Practice,
Organization Assessment Form
www.state.nj.us/health/bibs/education/ethnic.html
6
Assemble a patient visit team (provider, certified
diabetic nursing assistant, promotoras, intake
worker, lab, immunization, and referrals).
7
Use group visits to deliver care. A group visit
brings together 8 to 20 patients to deliver
medical care in a group setting; all patients are
in the same room, and providers come to the
group to take vital signs, discuss issues, and
answer questions.
Tips
Be cognizant of cultural diversity in your
patients and use ETHNIC as a framework for
culturally competent clinical practice.
Make group visits multidisciplinary, including
dental, podiatry, and ophthalmology.
Try holding group visits at homeless shelters,
housing or faith-based organizations.
Group Visit Starter Kit
Planning Group Visits for High-Risk Patients,
American Academy of Family Physicians
www.aafp.org/fpm/20000600/33plan.html
DIABETES TRAINING MANUAL
38
Delivery System Design
➤Make designated staff responsible for follow-up by various methods,
including outreach workers, telephone calls, and home visits.
Steps
1
Identify follow-up needs, such as eye exam,
dental care, HbA1c, labs, and visits.
2
Plan the follow-up approach, including who
will contact patients, how, and when.
3
Use phone, outreach workers, and mailings
for follow-up.
Tools and Resources
Tips
Generate reports from the registry to
discover those patients in need of follow-up
and generate contact lists.
Ask patients for best methods and times
to follow up for check-back visit, pharmacy
refills, etc.
DIABETES TRAINING MANUAL
39
Delivery System Design
➤ Use promotoras and community health worker programs for outreach.
Steps
1
Get senior leadership support and solicit help
in hiring and/or recruitment.
2
Identify responsibilities of promotoras and
community health workers (see tips column),
and plan how they will be documented.
3
Train promotoras and community health
workers.
4
Provide job shadowing for LEAP (Lower
Extremity Amputation Prevention) exam and
counseling.
5
Evaluate skill level of health workers
periodically.
Tools and Resources
Credentialing of Promotoras
fax: 956-447-0553
Words to the Wise, Bilingual Course
for Diabetes Promotoras, New Mexico
Department of Health Diabetes
Control Programs
505-827-2953
Tips
Try using the promotoras and community
health workers for:
• Clinical follow-up
• Community screening
• Home visit for follow-up care
• Participation in group visit
If promotoras are unpaid volunteers, provide
periodic incentives such as paper certificates
of appreciation, a local newspaper story,
awards recognition lunch, personalized tools
such as name tags or a blood pressure cuff
(often pharmaceutical companies will pay for
such items).
DIABETES TRAINING MANUAL
40
Organization of Health Care
Health care systems can create an environment in which organized efforts to improve
the care of people with chronic illness take hold and flourish. Critical elements
include a coherent approach to system improvement, leadership committed to and
responsible for improving clinical outcomes, and incentives to providers and patients
(including nonfinancial incentives such as recognition and status) to improve care
and adhere to guidelines.
Changes for Improving Organization of Health Care
➤ Make improving chronic care a part of the organization’s vision, mission, goals,
performance improvement, and business plans.
➤ Make sure the senior leaders and staff visibly support and promote the effort to
improve chronic care.
➤ Assign day-to-day leadership for continued clinical improvement.
➤ Integrate Collaborative models into the Quality Improvement program.
CASE STUDY
Salud Para La Gente, Inc.
Watsonville, California
The population served at Salud Para La Gente is primarily
migrant farm workers and their families. Fifty-seven percent of the patients are uninsured. One significant barrier
identified by the diabetes team was that the patients were
unable to afford the medications they needed to manage
their condition.
Senior leadership supported the efforts and provided the
resources to develop and maintain a tracking system to
enroll eligible patients in an Indigent Pharmacy Program.
The team developed a tickler system that prompts the
reapplication process and helps assure that diabetic
patients are receiving the medications they need to control
their condition—while saving the health center more than
$30,000 a month.
In addition to the senior leader’s support, the executive
director plays an active role on the diabetes team, attending Learning Sessions and team meetings regularly and
helping to eliminate multiple barriers along the way.
DIABETES TRAINING MANUAL
41
Organization of Health Care
➤ Make improving chronic care a part of the organization’s vision, mission, goals,
performance improvement, and business plans.
Steps
1
2
Tools and Resources
Link diabetes measures and outcomes to
the strategic business plan:
• Identify expense revenue from the organization’s Chief Financial Officer.
• Conduct a unit cost analysis by activity
center. For diabetes patients, model the
unit cost.
• Document change/time in outcome and
document treatment time of patients.
• Document revenue from ancillaries.
Tips
Business Case for Disease Management
www.improvingchroniccare.org
Discuss with senior leader the direct impact
that improved outcomes have on the organization. Provide references of other senior leaders
who have undertaken the same effort.
Assist senior leader in determining the “value”
of improving chronic illness care (e.g., quality,
accreditation, increased productivity/efficiency,
business case, and more patients).
Test different ways to get senior leader’s support. For example, present to the senior leader
in the language or areas of “worry” that the
senior leader thinks in. Ask the Collaborative
Directors for support and advice.
Involve the senior leader early on.
Involve the senior leader in developing an aim,
and ask the senior leader for feedback on the
draft aim statement.
Discuss the team’s choice of measures and how
they impact the organization and the patients.
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
42
Organization of Health Care
➤Make improving chronic care a part of the organization’s vision, mission, goals,
performance improvement, and business plans. (continued)
Steps
3
Gain the senior leader’s interest with reports
and feedback.
Tools and Resources
Tips
Use the Senior Leader Report, graphs, and
registry report, eliminating the need for a special report to be created for the senior leader.
Make a standing monthly appointment
with the senior leader/team leader and team
to discuss Senior Leader Report.
Provide Senior Leader Report 2 or 3 days
prior to meeting for review time and as a
reminder of the appointment.
Understand the data! Know what the
issues/barriers are, and present them in an
objective manner that invites the senior
leader to contribute.
4
Involve senior leadership with the team’s work.
Invite the senior leader to team meetings.
Assign the senior leader work in removing
barriers.
Involving the senior leader in work and decision
making helps build trust that the team will do
the right thing.
Involve the senior leader in marketing the
outcomes in the community for partnership
development.
DIABETES TRAINING MANUAL
43
Organization of Health Care
➤Make improving chronic care a part of the organization’s vision, mission, goals, performance
improvement, and business plans. (continued)
Steps
5
Tools and Resources
Have the team leader or physician champion
regularly report Collaborative work to Board
of Directors.
Tips
Keep it simple! Provide a straightforward
report that everyone can understand; avoid
being too technical or too clinical.
Provide patients’ own words or reactions whenever possible, or discuss provider satisfaction.
Provide printed reports and, if possible, do
overheads of graphs.
Present barriers to progress (e.g., transportation,
eye care, resource development) to Board of
Directors and seek their help in overcoming the
barriers.
6
7
Show Health Disparities Collaboratives
training and promotional videos to introduce
senior leaders, Board of Directors, and staff
to Collaborative work.
Place storyboards in places visible to
staff and patients.
Changing Practice, Changing Lives:
The Health Disparities Collaboratives,
Training and Promotional Videos
Use this excellent tool to get others involved.
www.healthdisparities.net
Post a sign reading, “For further information,
contact xxxxx.”
Create an “HbA1c Club” bulletin board
where patients who drop their HbA1c by 1%
get their picture taken (with their consent,
of course) and put up on the board — a real
reward for them and a motivator for other
patients and staff.
8
Post Senior Leader Report/graphs so staff
can review.
Assign team member to change posting monthly.
Post a sign reading, “For further information,
contact xxxxx.”
DIABETES TRAINING MANUAL
44
Organization of Health Care
➤Make sure the senior leaders and staff visibly support and promote the effort
to improve chronic care.
Steps
Tools and Resources
Tips
1
Encourage the senior leader to:
• Visit the clinical team.
• Speak about the improvement effort in
all-staff meetings.
• Participate in writing the aims and goals of
the diabetes initiative and provide guidance
for the clinical team.
• Make monthly updates to the community.
Invite the senior leader to make a 10-minute
presentation to the “community” at a group
diabetes class (make sure it is after the class
has been well-established so that there will be
enough people there to make it worthwhile).
Ask the patients at the class to give the senior
leader feedback.
2
Present local morbidity/mortality diabetes data
to the Board of Directors to make a compelling
case for the need to change current practice.
Ask for Board of Directors’ support early
and often.
Have the physician champion share tested
tools and interventions at provider meetings to
engage interest and involvement.
As tools are tested and proven, ask interested
providers to try them.
3
Give feedback to Board regarding how support
has made a difference.
Discuss data that is available from registry and
uses for data.
Provide copy of DEMS flowsheet for review.
At every provider meeting, share something
positive: a patient case study or a tool.
Involve providers by asking for their input
and ideas.
Don’t be afraid to share “learning opportunities”
— the ideas that did NOT work. Present patient
cases from which providers can learn about pitfalls, and reduce the fear of presenting mistakes,
dead ends, trials that show us what doesn’t
work and why. “Get messy! Make mistakes!”
DIABETES TRAINING MANUAL
45
Organization of Health Care
➤Make sure the senior leaders and staff visibly support and promote the effort
to improve chronic care. (continued)
Steps
4
Have team members present Collaborative
activities at staff meetings.
Tools and Resources
Tips
Ask the senior leader or Medical Director to
formally introduce the Collaborative and team
to promote the effort and ask other staff to
help when needed.
Provide patient comments as appropriate.
Be enthusiastic, so that others will want
to participate.
5
Have the senior leader help identify the most
enthusiastic and respected clinician to be on
the improvement team and test changes in
his/her practice.
DIABETES TRAINING MANUAL
46
Organization of Health Care
➤Assign day-to-day leadership for continued clinical improvement.
Steps
1
Have the senior leader provide time for a dayto-day team leader to manage the initiative.
2
Have the senior leader identify an enthusiastic
and respected clinician to champion the work
and the team.
Tools and Resources
Tips
Ask the Medical Director to advocate for
providing sufficient time for the day-to-day
leader’s work.
Choose a physician champion with the
following characteristics:
• Commitment to improve/change the system
• Ability to articulate needs of team without
alienating others
• Willingness to be a team member, not
the team
Have the team leader deal with day-to-day
activity, so that the physician champion will
not be overloaded.
3
Gain the partnership and trust of the CEO and
the Medical Director so that they will formally
delegate authority to the team to make change.
4
Select the improvement team and establish a
regular meeting time.
5
Engage administrative and clinical staff in the
diabetes project, so that people at all levels are
aware of the improvements.
6
Regularly evaluate the team process.
7
Make maintaining the progress part of
ongoing work.
8
Consider making the team a “pilot” with
plans to train other teams.
Make support of and participation in the
diabetes effort part of the annual evaluation
for all staff.
Health Disparities Collaboratives Train-theTrainer Manual for Health Centers
Senior leader should set this expectation early;
staff will be more willing to help because they
will want help when their turn comes.
DIABETES TRAINING MANUAL
47
Organization of Health Care
➤Integrate Collaborative models into the Quality Improvement program.
Steps
1
Tools and Resources
Enlist the person responsible for quality in the
organization as a team member.
Tips
Provide Prework Manual for review
and reference.
Involve quality person in aim and measure
development.
2
3
4
5
Get the team leader or physician champion on
the Quality Improvement Committee (QIC)
agenda each meeting to present some aspect of
the improvement work.
Provide a copy of this manual for all
members.
Engage the Quality Improvement Committee
in discussion of barriers or ideas to test.
Present barriers and ask for ideas.
Integrate the models (Care Model and
Improvement Model) into the quality improvement plan and use them for all improvements.
If possible, use overheads for graphs.
Report back on successes!
Care Model
www.improvingchroniccare.org
Improvement Model
Work with quality improvement person to
integrate models into written plan.
Plan training of all staff on the Improvement
Model.
Send all tested and implemented change ideas
to all sites early for implementation.
DIABETES TRAINING MANUAL
48
Community
Linkages between health clinics and community resources such as health departments,
churches, senior centers, and YMCA/YWCAs are crucial to the success of comprehensive
chronic illness care programs. Clinics form partnerships with community organizations
to develop evidence-based programs, resources, and health policies that support patients
in their efforts to manage chronic disease. Clinics with strong linkages to the community
make special efforts to coordinate chronic illness guidelines, measures, and resources
throughout the community. Clinics that make these important links to community
resources improve patient care and outcomes and enable communities and patients to
take an active role in managing chronic illness.
Changes for Improving Community
➤ Establish linkages with organizations to develop support programs
and policies.
➤ Link to community resources for defrayed medication costs, education,
and materials.
➤ Encourage participation in community education classes and
support groups.
➤ Raise community awareness through networking, outreach, and education.
➤ Provide a list of community resources to patients, families, and staff.
CASE STUDY
Dimock Community Health Center
Roxbury, Massachusetts
Dimock CHC conducted a community-based needs
assessment, surveying residents on prevalence of diabetes
and related symptoms, access to care, cultural and
linguistic needs and barriers, and reviewed a regional
analysis conducted on bilingual diabetes initiatives funded
by the Commonwealth Fund and others to assess the
needs of the community.
Based upon a data summary that presented the results of
the assessment and identified barriers to care and access,
the CHC approached local leaders in diabetes care, Beth
Israel-Deaconess Medical Center (BIDMC) and the Joslin
Diabetes center, about partnership to develop a communitycentered response to the needs assessment. Dimock CHC
subsequently received initial seed funding from BIDMC for
outreach workers (for one year) and in-kind and financial
support for clinical staff and technical assistance from the
Joslin (for four years). In addition, Dimock applied for a
grant with technical assistance from the local DPH (funded
for 15 months), developed community service rotations
with Northeastern University, Harvard Medical School, and
Emmanuel College nursing and medical programs, and
joined Latino Diabetes and REACH 2010 community coalitions, among others.
DIABETES TRAINING MANUAL
49
Community
➤Establish linkages with organizations to develop support programs and policies.
Steps
1
Tools and Resources
Identify key community organizations
(churches civic groups, clubs, schools, hospitals, banks, etc.) and let them know ideas for
what they can do to improve care of people
with diabetes. The community is a trusted
access point for reaching people with diabetes,
their families, and their friends to support
them in learning more about diabetes and
gaining control over it.
Tips
National Diabetes Education Program,
Diabetes Community Partnership Guide,
page 51, “Organizations Making a Difference
with 18 Easy Ideas.”
ndep.nih.gov/materials/pubs/communityguide/community-guide.htm
National Diabetes Education Program
800-438-5383 or ndep.nih.gov
Center for Disease Control and Prevention
2
3
4
Identify local/state interest groups: PCA
(Primary Care Association), Diabetes Control
Program (DCP), etc.
Before developing a relationship, review
missions of different organizations to ensure
compatibility.
Identify team/clinic needs (technical, staff,
hardware, strips, etc.) and approach other
community organizations for help.
www.cdc.gov/diabetes.
Translation for Educational Materials:
www.freetranslations.com
www.systranet.com
Find sources for interpreters to assist with
education, training materials, etc.
Get feedback from community partners to
find out how they can provide support for the
community learning more about diabetes, and
to suggest others who might be willing and
able to play a role.
Review partnerships to determine which are
politically or financially worth continuing.
Use data from the registry to help other organizations understand the needs of your diabetic
population and to show them the results of
any improvements you have made.
Diabetes Today National Training Center
training and technical assistance on
applying a community mobilization model,
Diabetes Today
www.diabetestodayntc.org/
Summit Health Institute for Research and
Education (SHIRE), faith-based relationships
301-559-4400
Tools and Resources Icons
Web link
Form/Tool that may be
accessed on
www.healthdisparities.net
Book or periodical
reference
Form/Tool that may be
accessed via a web link to
another site
Phone reference
DIABETES TRAINING MANUAL
50
Community
➤Establish linkages with organizations to develop support programs and policies. (continued)
Steps
5
Request education and services from universities, colleges, and extension services.
6
Develop memoranda of understanding
or similar documents as needed to define
partnerships.
7
Prepare a brief presentation that outlines the
goals of the diabetes project, the mission of
your organization, and what you are striving
to do for the community you serve. Offer to
do the presentation to local service organizations, ADA conferences, university- or professional organization-sponsored workshops.
8
Work with Americorps or VISTA to place
staff to work on the diabetes project.
9
Ask for community representatives to attend
and be part of advisory groups.
10
Identify clinic leadership to serve on community boards.
Tools and Resources
PCA Directory Listing
State Based Programs to Reduce the
Burden of Diabetes
Tips
Use high school and college students pursuing
careers in health to provide patient outreach,
computer expertise, materials development
assistance, etc., as part of a school project.
Present your needs to schools.
Periodically review partnerships and agreements to determine success.
Americorps
www.americorps.org/
DIABETES TRAINING MANUAL
51
Community
➤Link to community resources for defrayed medication costs, education, and materials.
1
Steps
Tools and Resources
Tips
Request supplies (glucose meters, strips) and
unrestricted grants from pharmaceutical firms
and local stores/pharmacies. Usually, all that
is needed is a letter (signed by an MD always
helps) requesting an unrestricted educational
grant or an unrestricted grant to improve
diabetes patient care. Usually $500 to $1000
can be obtained from a single company
without difficulty. Contact your local pharmaceutical company representatives and ask
what is required to obtain such a grant from
their firms.
Patient Prescription Services:
When approaching organizations for help,
quantify requests clearly.
Bayer Corporation/Bayer Indigent Patient
Program
800-998-9180
Bristol-Myers Squibb Patient Assistance
Program
800-437-0994
Eli Lilly & Company/Lilly Cares
800-545-6962
Hoechst Marion Roussel, Inc./Indigent
Patient Program
800-2114025
NovoNordisk Pharmaceuticals Inc/
Indigent Program
800-727-6500
Pfizer Inc/Pfizer Prescription Assistance
• Example: Request for free strips from Bristol
Meyers for one year
500 patients x $60/mo x 12 months = $360,000
Distribution costs per patient (staff time +
mailing + data entry) = _____________________
Total = _____________________
• Example: Request for support for referring
50 patients for diabetic classes at the YMCA
The health center will provide the
transportation.
50 x $3.00 = $150
3 hours of staff time for scheduling, etc.
$10 x 50 patients = $500 (covered by the
Women’s Group at the Baptist Church)
Total = _____________________
Make face-to-face contact for requests. This
generally works better than letters, except for
formal grant requests.
Patient Prescription Services is a company that
helps indigent patients get meds from pharmaceutical programs with much less effort than
the usual application process. It comes as a
software package or a direct service. The software package has been previewed by MCN; it
allows provider modification, acting as a medicine flow sheet and problem list.
Ask all pharmaceutical representatives who
detail the office for unrestricted grants to
support the effort.
Ask the senior leader to allow staff to present
to potential funders as paid time.
DIABETES TRAINING MANUAL
52
Community
➤Link to community resources for defrayed medication costs, education, and materials. (continued)
Steps
2
Obtain free passes/memberships from local
YMCA/YWCA for people with diabetes. Don’t
forget about free passes to other places that
encourage walking as a physical activity (the
zoo or botanical gardens, etc.).
3
Request in-kind services from local specialty
groups (ophthalmology, endocrinology,
dental, etc.).
Tools and Resources
Tips
National Eye Care Project Helpline,
No-Cost Ophthalmology Exam
1-800-222-EYES.
American Optometric Association,
Optometry Referral and Follow-up
800-262-3947
4
Involve the clinic pharmacy to increase
participation in drug assistance programs.
5
Develop form with pharmacist for each
indigent program. Make arrangements with
local pharmacy.
Maintain a sample application from each
patient using the indigent drug program to use
for obtaining refills.
Tie refills in with planned visits (see Delivery
System Design).
6
Identify community provider resources
(e.g., specialists, dentists) for referral.
Present information about the diabetes
improvement project and request funding.
DIABETES TRAINING MANUAL
53
Community
➤Link to community resources for defrayed medication costs, education, and materials. (continued)
Steps
7
Complete a grant request to the local
Diabetes Control Program for additional
staffing/equipment (e.g., computers).
8
Request funding from service organization
(Lions, etc.) for specific item or equipment or
services (e.g., Bayer DCA 2000).
9
Complete grant requests from national
organizations (e.g., Pearle Vision).
10
Request discounts on fruits/vegetables or
catered meals for special education programs
or health fairs from local grocery chains.
11
Advocate for expanded Medicaid benefit
packages.
Tools and Resources
Tips
Ask senior leaders and Board of Directors
to help you identify and find possible grant
opportunities or funding sources.
Invite Medicaid managed care leaders to be
involved in the team.
DIABETES TRAINING MANUAL
54
Community
➤Encourage participation in community education classes and support groups.
Steps
1
Review class curricula for compatibility
with the clinic’s self-management approach
and cultural differences.
2
Review the system for referring patients to the
community agency offering the class or group.
3
Use the registry to mail out fliers to patients.
Include an endorsement from providers or
respected community figures.
4
Use volunteers to remind patients.
5
Maintain close communication with the
community sponsor.
6
Evaluate class/group with patients.
Tools and Resources
Culturally Appropriate Patient Education
Materials, Office of Minority Health
www.omhrc.gov/
Tips
Make sure the agency offering the class/group
has a similar mission to yours and that both
will benefit from the referrals.
Be willing to work with the agency to help
make their curriculum compatible.
Constantly keep cultural sensitivity in mind.
Assign a staff member to be a key contact and
identify a key contact at the partner agency.
“Prescribe” the class/group using a prescription pad.
Anticipate that transportation to classes/groups
may be a barrier for some patients, and find
solutions.
Keep in touch with patient participants if it is
an ongoing class/group to determine problems,
barriers, and provide feedback and support.
If the cost of patient education classes is a
problem for some uninsured patients, offer to
trade: A staff physician will talk at a class
about diabetes meds or complications in return
for a “scholarship” for an indigent patient to
take the classes.
DIABETES TRAINING MANUAL
55
Community
➤Raise community awareness through networking, outreach, and education.
Steps
Tools and Resources
1
Sponsor health fairs and education. Focus on
special populations (ethnic, cultural, etc.).
Take Control of Diabetes Manual, Centers for
Disease Control and Prevention for Training
Community Health Workers (Spanish)
2
Provide education to people at shelters
and soup kitchens about diabetes, diet,
exercise, etc.
www.cdc.gov/diabetes/pubs/pubs.htm
3
Work with churches or faith-based organizations or other groups where your patients
naturally gather, for instance, barbershops
and hair salons, Provide space for meeting,
transportation for patients to get to meetings
and appointments, provide screening for
diabetes and hypertension, education, peer
support groups, communication channels to
patients and families, etc.
4
Recruit and train migrant/homeless community
health workers (CHWs) to assist in education
and screening outreach programs.
5
Recruit and train CHWs to link patients and
providers (e.g., chart flagging, lab/referrals,
outreach, education, and transportation).
6
Have CHWs assist during support group meetings (e.g., providing testimonials or helping
with food demonstrations).
7
Have a school health fair for primary prevention and to teach kids what problems their
parents with diabetes may have. Children can
be very effective communicators for effecting
patient behavior change. Remember the patient
who decides to quit after his child says, “Please
stop smoking. I don’t want you to die.”
Diabetes and Homelessness: Overcoming
Barriers to Care, Manual
www.nhchc.org/hot.html#diab.hot
Tips
Note that the American Diabetes Association
2001 clinical practice guidelines do not recommend community screening. Fingerstick
screening at health fairs should be minimized.
Healthy lifestyle education and prevention
activities like foot screening for diabetics may
be a better use of resources.
Some successful health fairs have included
educational offerings for providers (first two
hours are provider in-service with outside
speakers, followed by a public event with
outside speakers addressing patients).
Be sensitive to “turf” issues to maximize
successful partnerships.
Obtain support through Diabetes Control
Program (DCP) funding sources.
See “Care Model Changes for Specific
Populations” in this manual for ideas relating
to homeless/migrant populations.
DIABETES TRAINING MANUAL
56
Community
➤Provide a list of community resources to patients, families, and staff.
Steps
Tools and Resources
Tips
1
Identify existing lists of resources.
2
List the shopping malls that open early (and
their hours) to accommodate walkers. Find out
whether there is a shuttle or mall security available to safely escort walkers to the bus stop.
3
Assign a staff member or volunteer to collate
lists, update information, and review for
accuracy. Collect contact information and
guidelines for program use.
Create a notebook or computer database
of resources.
Contact local Senior Information and
Assistance Program (federally mandated program) to avoid duplication of effort while
building the resource guide.
Look in phone book for Senior Information
and Assistance—every community has this
resource.
4
Check first to see if another community
agency has already developed a resource guide,
such as the Chamber of Commerce list of
organizations.
Update information routinely.
DIABETES TRAINING MANUAL
57
Diabetes
Care Model: Changes for Specific Populations
The Care Model has been found useful in a
wide range of settings for different populations. Teams working with unique groups may
find that the emphasis on some model elements require greater emphasis than others.
For example, self-management is very important for migrant populations who may seek
health care in several geographic areas, while
community linkages are crucial when working
with homeless populations. In some cases,
adaptation of key changes will be necessary.
For example, pictorial educational information will be helpful for populations with
low literacy.
Self-Management
The following ideas from other community
health centers with experience applying the
Care Model in a wide variety of settings may
be helpful to you.
➤ Translate/adapt recipes.
➤ Address mobility in self-management issues.
➤ Use Track II, encouraging patients to
bear responsibility for their own care and
follow-up.
➤ Provide a cassette tape of patient education/provider instructions for mobile
patients to listen to when traveling.
➤ Promote patient-led support groups.
➤ Offer evening, self-management clinics
after work hours.
➤ Promote Track II participation and
portable record carrying.
➤ Provide self-management goal setting that
is culturally specific and includes family
(e.g., how to choose food in a camp or
shelter setting, how to obtain medication
refills in a new site, etc.).
➤ Address occupational needs, such as
self-management in the fields, foot care in
the fields or on the street, snacks in the
shelter, etc.
➤ Provide information on best choices from
fast food restaurants.
➤ Use low-literacy tools for goal setting.
➤ Assess literacy level of all patient education
materials and revise as needed.
➤ Provide glucometer and medication training, using low literacy techniques.
DIABETES TRAINING MANUAL
58
Care Model: Changes for Specific Populations (continued)
Decision Support
Clinical Information System
Delivery System Design
➤ Videotape preventive care instructions and
play at all sites.
➤ Create flow sheets/portable records
for migrant workers to take from center
to center.
➤ Provide after-hours clinics at the centers.
➤ Offer provider education and updates on
the special needs of farm workers through
meetings, MCN, literature review, and
web-based learning.
➤ Include migrant population in the registry.
➤ Take medical and dental care to the people
(the farms, the camps, the shelters).
➤ Enroll migrant and homeless in Track II,
the national tracking and referral project
for migrating patients with diabetes. If you
need information on Track II, you may call
Carmel Drewes at MCN: 512-327-2017 or
by email: [email protected].
➤ Work with local migrant health centers
(MHC) to identify common patients and
develop a referral process and information
transfer between the CHC and MHC.
Consider sharing of services, e.g., in linked
sites, one could do dental and the other
could do eye care.
➤ Provide a tool for patients to track their
yearly care needs.
➤ Train patients and providers on use of
Track II.
➤ Develop communication between clinic
sites that routinely share patients.
➤ Provide group visits in all locales.
➤ Follow special population data and be
proactive about what you want to know
from your data.
➤ Provide information system support from
the main health center if the homeless or
migrant site is small or rural.
➤ Provide shower facilities for patients in
order to assist with personal care and promote attendance.
➤ Include oral health in all care visits for
special populations.
➤ Incorporate Track II into routine service
provision.
➤ Offer walk-in or same-day appointments
for preventive and chronic care needs.
➤ If possible, offer low-sugar, low-fat snacks
as an incentive to come to clinic, and to
show an example of healthful food choices.
➤ Provide after-hours clinics at the centers.
➤ Take medical and dental care to the people
(the farms, the camps, the shelters).
DIABETES TRAINING MANUAL
59
Care Model: Changes for Specific Populations (continued)
Organization of Health Care
Community
➤ Use staff who are native speakers and
promote language competency in staff.
➤ Identify community leaders who will serve
as champions in the community.
➤ Provide resources for training opportunities
for language development and local literacy
promotion programs for the patients in the
community.
➤ Have focus groups from the community
help select teaching tools appropriate for
the population.
➤ Collaborate with local hospitals, medical
equipment suppliers, and specialty care
providers to provide camp/shelter/motel
on-site services and products.
➤ Adapt center hours to accommodate farm
labor schedules.
➤ Consider off-site care delivery in the farm
or camp setting.
➤ Provide child care during classes.
➤ Provide transportation to classes.
➤ Network with Migrant Head Start
and Migrant Education Programs to collaborate in identifying and caring for migrant
families.
➤ Provide community health worker training
for outreach and education (promotoras).
➤ Use natural leaders on the health care team.
➤ Supply vouchers for dental, eye, and
foot care.
➤ Coordinate diabetes education and screening for patients with kindergarten and
school screenings for children.
➤ Have adult flu and Pneumovax available
at pediatric immunization clinics.
➤ Have health fairs especially oriented to
migrant/homeless populations.
➤ Find out the interests of faith-based and
civic groups in the community and look
for ways to join them in health promotion
to migrant and homeless populations.
➤ Collaborate with area faith communities
to enhance care provision.
➤ Explore glucometer and medication
vouchers.
➤ Utilize Americorps volunteers.
➤ Link with medical school volunteers.
➤ Start a community sock-donation program.
➤ Collaborate with the local soup kitchen in
nutrition education and meal planning.
DIABETES TRAINING MANUAL
60
Diabetes
Improvement Model
The Improvement Model consists
of three fundamental questions
and a Plan-Do-Study-Act cycle to
test and implement changes in
real work settings.
What are we trying to accomplish?
Aims
How will we know that a change
is an improvement?
Measures
What changes can we make
that will result in improvement?
Changes
ACT
PLAN
STUDY
DO
*The Improvement Model was developed by Associates
in Process Improvement.
DIABETES TRAINING MANUAL
61
Setting an Aim
An aim is an explicit statement summarizing what your organization hopes to achieve. It helps to focus on specific actions to
implement the Care Model, and to define which patients and
providers will participate. Your aim statement should also be
time-specific and measurable. The aim and selected measures
should be “stretch goals,” not achievable in the current system of
care. The aim should incorporate various components of the Care
Model and emphasize that system redesign will be taking place.
Example: We will redesign the
office practice so that, within
nine months, more than 70%
of the patients with diabetes will
have their last blood pressure
below 140/90 and the average
HbA1c will drop to below 8.0
by implementing the components of the Care Model.
In setting your team’s aim, be sure to do the following:
➤ Involve the organization’s senior leaders.
What are we trying to accomplish?
How will we know that a change
is an improvement?
What changes can we make
that will result in improvement?
Leadership must align the aim with the strategic goals of the organization.
➤ Base the aim on both data and organizational needs.
Examine data within your organization to help guide the establishment of an appropriate
aim. Refer to the measurement section, and focus on issues that matter to the organization.
➤ State the aim clearly and use numerical goals.
ACT
PLAN
STUDY
DO
Teams make better progress when they have unambiguous, specific goals. Setting numeric
targets clarifies the aim, helps people focus for change, and directs measurement. For
example, an aim to “increase the percentage of patients with self-management goals by
50%” will be more effective than an aim to “improve patient self-management practices.”
➤ Include appropriate guidance on approaches and methods.
Describe the practice (office, clinic, practice team, etc.) and the patient population that will
be the focus of this aim. Include specific strategies that the organization intends to follow.
Guidance
To augment the specific aim statement,
the team may want to provide additional descriptive criteria. This is often
referred to as “guidance” to the aim.
Example: Our health center will develop and maintain a
registry of all 250 of our patients with diabetes. We will
focus initially on patient self-management methods and
delivery system design. Two of the four physicians will
be involved in the process at first. Once the changes
have been implemented, the other two physicians and
their panels will be included.
DIABETES TRAINING MANUAL
62
Setting an Aim
Patients with Diabetes:
Population of Focus
A Definition
The Care Model is population-based.
Population-based care is the process of identifying health problems within a specific
population of patients, defining and assuring
evidence-based interventions for members
of that population, and regularly monitoring
progress and scientific literature to keep
interventions state-of-the-art.
To identify the patient population, the team
needs to be able to access data that can distinguish populations with different health
problems. ICD 9 or CPT codes from billing
data are the most common source for making these distinctions. The ability to tie
billing codes to individual patients allows
you to generate lists to contact and track
patients for delivery of proven interventions,
and to monitor their progress over time.
Patient lists (or registries, as they are commonly called) can vary in complexity from
manually maintained spreadsheets that
contain the patients’ names and contact
information (at a minimum) to an on-line
software system that provides data query
capabilities and care planning.
Many health centers provide care to hundreds, or even thousands, of patients with
diabetes. Similarly, many centers have multiple sites and providers. It is not reasonable to
expect that care for all patients can be significantly redesigned at one time. It is strongly
recommended that a team pick a sub-group
(or sub-population) of patients with diabetes
to be the focus of the change in practice.
There are two criteria for selecting this
sub-population (which we will refer to as
“Population of Focus,” or POF).
➤ The total size of the population should
be between 100 and 300 patients.
➤ The patients should be selected based
on either clinic or provider, or both.
For example, if at one clinic there are two
providers with approximately 160 patients with
diabetes, your Population of Focus could be all
patients of both providers seen at this clinic.
Note that the selection of the population of
focus should not be based on risk levels or
any demographic factors (only by provider
and/or clinic). Pick the population of focus
wisely. Pick the providers and clinics where
the changes are most likely to be embraced.
The following definition is used to identify
patients with diabetes:
“Patients with diabetes (Type 1 and Type
2), 18 to 75 years old, who were continuously enrolled during the year, and who
have at least one visit to the clinic within
the past calendar year are considered clinic
patients unless there is documentation that
the patient has transferred to another practice or has moved from the area.”
In addition, clinics with managed care
plans should try to include patients with
diabetes who have no documented medical
visit to the clinic, and who have been
assigned to the clinic for 12 months, with
no more than a 45-day drop in coverage.
Once you have selected the population of
focus, your team will concentrate improvement efforts on that group of patients. This
does not mean that changes that are found
to be effective with the population of focus
cannot be spread to other clinics or providers.
It only means that the initial effort and measurement will be directed toward this group.
Example of Population of Focus (POF): Initially, we
will focus on the patients of two of the four providers
(Smith and Jones) at the Best Clinic site. This
includes approximately 250 patients with diabetes,
all of whom were seen at the clinic in 2001.
DIABETES TRAINING MANUAL
63
➤ For the current national measures, visit the
Health Disparities Collaboratives website at
www.healthdisparities.net
Establishing Measures Related to Your Aim
The Why, What, and How Much of Measurement
Your health center’s goal is to improve care for people with diabetes, not to design a
perfect measurement system. But measurement will play an important role in your
efforts to improve care. Measurement will help you evaluate the impact of changes you
make to improve the delivery of care to the population of persons with diabetes. Always
remember that measurement should be designed to accelerate improvement, not slow
it down. Your team needs just enough measurement to be convinced that the changes
you are making are leading to improvement, and no more.
Guidelines for Getting Started
➤ Plot data over time.
What are we trying to accomplish?
How will we know that a change
is an improvement?
What changes can we make
that will result in improvement?
Improvement in care of patients with chronic conditions will require continuously testing and implementing changes. Most of the information about performance of your
system and how it has improved can be learned by observing trends and patterns in
simple run charts (time series plots) of key measures directly related to your aim.
ACT
PLAN
STUDY
DO
➤ Focus on measures directly related to your aim.
Measures that can be used to evaluate performance of the system relative to your
team’s aim should be maintained on a regular basis. You may also want to use
balancing measures (measures that track the effect that changes in one part of a
system have on other parts of the system).
➤ Use the registry as the basis for your measures.
The registry is a basic part of the clinical information system that will be part of
your practice redesign. You can also use it to develop most of your key measures on
the patient population of interest.
➤ Integrate measures into routine processes.
Whenever possible, collect useful data as part of the normal performance of a work.
Auditing charts is a very non-productive way to obtain data for measures. Update
the registry after each patient visit. Develop simple data recording forms that are integrated into the patient visit.
DIABETES TRAINING MANUAL
64
Testing and Implementing Changes
Depending on their aim, teams choose promising changes from different elements of the
Care Model and test them in their specific practice settings. Teams use Plan-Do-Study-Act
(PDSA) cycles to test a change quickly on a small scale, see how it works, and refine the
change as necessary before implementing it on a broader scale.
The following example shows how Rocky Road Health Center developed and tested the
use of an electronic registry to improve the measurement of HbA1c.
What are we trying to accomplish?
How will we know that a change
is an improvement?
PDSA Cycle Example:
Step 4: Act
Step 1: Plan
After a team meeting with the executive director
and the finance officer who also oversees the
information system, the health center adapted
a scannable flow sheet form they had learned
about from the Midwest Clinicians Network.
At the finance officer’s suggestion, they added
patients’ insurance status to make sure eligible
patients were enrolled in Medicaid or Medicare.
To cut down on cycle time, the medical records
of the diabetic patients were reviewed the night
before to identify gaps and to pre-enter data.
The team at the Rocky Road Health Center
predicted that a registry of patients with diabetes
would improve the measurement of HbA1c.
Setting up this system took 3 weeks. During
that time, the health center also established
protocols for glucose measurements and ran
a trial utilizing patient self-management for
home glucose measurements.
ACT
Step 3: Study
STUDY
The time spent on completing the flow sheet
increased from 1 minute to 2 minutes, and it
took an additional 3 minutes to enter data into the
registry. Waiting time for diabetic patients
increased an average of 8 minutes.
Of the patients with diabetes, only half had
appropriate testing of HbA1c; but after the trial,
all of these patients had current values.
PLAN
DOStep
What changes can we make
that will result in improvement?
ACT
PLAN
STUDY
DO
2: Do
The registry was tested for 2 weeks
with one enthusiastic volunteer nurse practitioner and her patients with diabetes. After the
Diabetes flow sheet was revised to reflect the
registry information, the collection went well.
The health center could run additional PDSA cycles to test ways of using time even more
effectively. In addition, the health center could run simultaneous PDSA cycles to test
changes in patient self-management of glucose levels.
DIABETES TRAINING MANUAL
65
Diabetes
Bibliography*
Clinical Management
Diabetes Control and Complications Trial
Research Group. The effect of intensive treatment of diabetes on the development and
progression of long-term complications in
insulin-dependent diabetes mellitus. NEJM.
1993;329:977-86.
This is the definitive trial of tight glucose
control in patients with Type I diabetes,
demonstrating decreased complications with
improved glucose control.
Eakin EG, Bull SS, Glasgow RE, Mason M.
Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations. Diabetes Metab Res
Rev. 2002 Jan-Feb;18(1):26-35.
*The diabetes bibliography was developed by
Improving Chronic Illness Care, a National Program
of the Robert Wood Johnson Foundation, and is
available online at www.improvingchroniccare.org.
Litzelman DK, Slemenda CW, Langefeld CD,
et al. Reduction of lower extremity clinical
abnormalities in patients with non-insulindependent diabetes mellitus. A randomized,
controlled trial. Ann Intern Med. 1993 Jul
1;119(1):36-41.
An intervention designed to reduce risk factors
for lower-extremity amputations positively
affected patient self-foot-care behavior, as well
as the foot care given by health care providers,
and reduced the prevalence of lower-extremity
clinical disease in patients with diabetes.
Sadur CN, Moline N, Costa M, Michalik D,
Mendlowitz D, Roller S, Watson R, Swain BE,
Selby JV, Javorski WC. Diabetes management
in a health maintenance organization: Efficacy
of care management using cluster visits.
Department of Medicine, Kaiser Permanente
Medical Care Program, Northern California,
Pleasanton 94588, USA. Diabetes Care.
United Kingdom Prospective Diabetes
Study Group. Cost effectiveness analysis of
improved blood pressure control in hypertensive patients with type 2 diabetes:
UKPDS 40. BMJ. 1998;317:720-26.
The UKPDS is a landmark study demonstrating the effectiveness of improved glycemic
control on decreasing complications of Type
II diabetes. Additional studies in the same
population underscore the importance of maximizing blood pressure control.
United Kingdom Prospective Diabetes Study
Group. Tight blood pressure control and risk
of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ.
1998;317:703-13.
United Kingdom Prospective Diabetes Study
Group. Efficacy of atenolol and captopril
in reducing risk of macrovascular and microvascular complications in type 2 diabetes:
UKPDS 39. BMJ. 1998;317:713-20.
United Kingdom Prospective Diabetes Study
Group. UKPDS 28: A Randomized Trial
of Efficacy of Early Addition of Metformin
in Sulfonylurea-Treated Type 2 Diabetes.
Diabetes Care. 1998;21(1):87-92.
DIABETES TRAINING MANUAL
66
Bibliography: Diabetes (continued)
Primary Care Interventions
Aubert R, Herman W, Waters J, et al. A
randomized controlled trial of nurse case management within an HMO to improve glycemic
control in patients with diabetes. Ann Intern
Med. 1998 Oct 15;129(8):605-12.
This trial demonstrates the effective use of
care managers within a primary care setting
in achieving significant improvement in
glycemic control.
Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for
chronically ill older HMO members:
The cooperative health care clinic. JAGS.
1997;45:543-49.
Evidence that group visits can provide clinical
care and result in beneficial outcomes for
patients and providers.
Behavioral Medicine Symposium. HMO
Practice. 1995;9.
This issue is devoted to assisting primary care
clinicians in caring for patients with behavioral
problems. It includes brief descriptions of programs that work and how providers integrate
behavioral techniques into their practice.
Brown JE, Glasgow RE, Toobert DJ.
Integrating dietary self-management counseling into the regular office visit. Practical
Diabetol. 1996 Dec;16-22.
Examines the successes, difficulties, and implications of integrating patient self-management
support, particularly dietary self-care
regimens, into primary-care office visits.
Population-Based Care
Glasgow RE, Boles SM, Calder D, Dreyer L,
Bagdade J. Diabetes care practice in primary
care: results from two samples and three
guidelines. Diabetes Care. In press.
A meta-analysis of adherence to guidelines
and discussion of the need for alternative
measurement approaches.
Gohdes D, Rith-Najarian S, Acot K, Shields
R. Improving diabetes care in the primary
health setting: The Indian Health Service experience. Ann Intern Med. 1996 Jan 1;124(1 Pt
2):149-52.
The Indian Health Service provides a model
of using standards and feedback to improve
care of patients with diabetes.
Wasson J, Gaudette C, Whaley F, Sauvigne A,
Baribeau P, Welch HG. Telephone care as a
substitute for routine clinic follow-up. JAMA.
1992;267:1788-93.
The first randomized clinical trial demonstrating cost savings and satisfactory care from
substituting regularly scheduled, proactive
phone calls for some clinic visits.
Weinberger M, Kirkman MS, Samsa GP, et al.
A nurse-coordinated intervention for primary
care patients with non-insulin-dependent
diabetes mellitus: impact on glycemic control
and health-related quality of life. J Gen Intern
Med. 1995;10:59-66.
This study demonstrates a pragmatic, lowintensity adjunct to care delivered by
physicians that improved glycemic control.
Friedman NM, Gleeson JM, Kent MJ, Foris
MF, Rodriguez DJ. Management of diabetes
mellitus in the Lovelace Health Systems;
EPISODES OF CARE program. Effective
Clinical Practice. 1998;1:5-11.
This article describes the comprehensive diabetes program used in a managed care setting
that resulted in improved diabetes care.
McCullouch DK, Price MJ, Hindmarsh M,
Wagner EH. A population-based approach to
diabetes management in a primary care setting: early results and lessons learned.
Effective Clinical Practice. 1998 AugSep;1(1):12-22.
Payne TH, Galvin MS, Taplin SH, Austin B,
Savarino J, Wagner EH. Practicing populationbased care in an HMO: Evaluation after 18
months. HMO Practice. 1995;9:101-6.
Describes the experience of one practice team
in providing population-based care, demonstrating improved guideline implementation
and screening compliance.
Renders CM, Valk GD, Griffin S, Wagner EH,
Eijk JThM van, Assendelft WJJ. Interventions
to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Review, The Cochrane
Library, Issue 1, 2002.
DIABETES TRAINING MANUAL
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Bibliography: Diabetes (continued)
Self-Management
Vogt TM, Hollis JF, Lichtenstein E, Stevens VJ,
Glasgow R, Whitlock E. The medical care
system and prevention: the need for a new paradigm. HMO Practice. 1998; 12(1):5-13.
Reviews the priorities, effective use of
resources and barriers to action in the use of
preventive services, with recommendations
for changing the paradigm.
Anderson RM, Funnell MM, Butler PM,
Arnold MS, Fitzgerald JT, Feste CC. Patient
empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18:943-49.
This wait-listed trial of empowerment techniques for patients with diabetes demonstrated
improved self-efficacy and blood glucose
control favoring the intervention.
Von Korff M, Gruman J, Schaefer J,
Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med.
1997;127:1097-102.
This review article with an extensive bibliography describes the elements of collaborative care.
Anderson RM, Funnell MM, Arnold MS.
Using the empowerment approach to help
patients change behavior. In: Anderson B,
and Rubin R, eds. Practical Psychology for
Diabetes Clinicians. Alexandria, VA:
American Diabetes Association; 1996.
Based on sound principles of counseling and
educational psychology, this chapter examines
the roles of provider and patient based on the
significant differences between the treatment
of acute diseases and diabetes.
Wagner EH. Population-based management
of diabetes care. Patient Educ Couns.
1995;26:225-30.
This article provides an overview of the steps
involved in population-based care.
Wagner EH, Austin BT, Von Korff M.
Organizing care for patients with chronic
illness. Mil Quarterly. 1996;74(4):511-44.
Comprehensive discussion of the model
for improving chronic illness care.
Wagner EH. Chronic disease management:
What will it take to improve care for chronic
illness? Effective Clinical Practice. 1998;1:2-4.
This editorial introduces an entire issue
devoted to chronic illness care and is the first
article publishing the model for improvement
of chronic illness.
Glasgow RE, Toobert DJ, and Gillette CD.
Psychosocial Barriers to Diabetes SelfManagement and Quality of Life. Diabetes
Spectrum 2001 14: 33-41.
Lorig KR, Sobel DS, Stewart AL, et al.
Evidence suggesting that a chronic disease
self-management program can improve
health status while reducing utilization and
costs: A randomized trial. Med Care. 1999
Jan;37(1):5-14.
Research basis for the Chronic Disease SelfManagement Program developed by the
Stanford Patient Education Research Center.
Glasgow RE, La Chance PA, Toobert DJ,
Brown J, Hampson SE, Riddle MA. Long
term effects and costs of brief behavioural
dietary intervention for patients with diabetes
delivered from the medical office. Patient Educ
Couns. 1997;32:175-84. See Aubert above.
This study evaluates the effectiveness of a
single session intervention involving touchscreen computer-assisted assessment the
provided feedback on key barriers to dietary
self-management.
DIABETES TRAINING MANUAL
68
Diabetes
List of Tools and Resources
Self-Management
American Association of Diabetes Educators
Diabetes Patient Questionnaire
Self-Management Support Tool
Diabetes Self-Management Goal Setting
(English and Spanish)
State-Based Diabetes Control Program
Group Visit Agenda
State Diabetes Control Programs
www.aadenet.org
American Diabetes Association
www.diabetes.org
Article on a motivational intervention to
improve care in Type 2 diabetes
fampract.oupjournals.org/cgi/reprint/15/3/229.pdf
www.cdc.gov/diabetes/states/index.htm
www.cdc.gov/diabetes/pubs/glance.htm#dcp
Stoplight Tool for HbA1c and
Blood Sugar Targets
Bayer Institute for Health Care, Patient
Communication Training
Health Professional Training and Patient
Education in Diabetes (University of
Michigan Diabetes Education Center)
www.bayerinstitute.org
www.med.umich.edu/mdrtc
Take Charge of Your Diabetes,
for Patients
Chronic Disease Self-Management Program
(CDSMP)
National Diabetes Education Program
www.cdc.gov/diabetes/pubs/pdf/tctd.pdf
www.stanford.edu/group/perc/cdsmp.html
Dental Self-Management Tool
www.cdc.gov/diabetes/projects/ndeps.htm
Self-Management Checklist
(to Enhance Your Self-Management)
Turning Patient Education into
Self-Management, Training Instructions
for Providers
Self-Management Coordination Matrix
Diabetes Goal Contract
(English and Spanish)
DIABETES TRAINING MANUAL
69
Diabetes: List of Tools and Resources (continued)
Decision Support
7 Principles for Controlling Your Diabetes
for Life (English and Spanish)
ndep.nih.gov/materials/puborder/
resource.htm#people
Centre for Evidence-Based Medicine
cebm.jr2.ox.ac.uk
Clinical Evidence for Providers
[email protected] or 877-485-8074
Cochrane Reviews
www.cochrane.org/cochrane/revabstr/
mainindex.htm
Control Your Diabetes. For Life.
Tips for Feeling Better and Staying Healthy
(English and Spanish)
ndep.nih.gov/materials/puborder/
resource.htm#people
Diabetes Care Chart Audit
Fax-back Form
Patient Guide for Diabetes Management
Hemoglobin A1c and Blood Sugar Targets
Patient Tips for Good Control
(English and Spanish)
If You Have Diabetes, Know Your Blood
Sugar Numbers (English and Spanish)
Take Care of Your Feet for a Lifetime
(English and Spanish)
ndep.nih.gov/materials/puborder/
resource.htm#people
ndep.nih.gov/materials/puborder/
resource.htm#people
Indian Health Service,
Patient Education Materials
Trip Database
www.ihs.gov/medicalprograms/diabetes
National Guideline Clearinghouse
The Unit for Evidence-Based Practice
and Policy
www.guideline.gov
www.ucl.ac.uk/openlearning/uebpp/uebpp.htm
National Institute for Diabetes & Digestive
& Kidney Disease
Wallet Card
www.niddk.nih.gov/health/diabetes/pubs/
complications/teeth/teeth.com
Netting the Evidence
Diabetes Flow Sheet
www.shef.ac.uk/~scharr/ir/netting
New Zealand Guidelines Group
Diabetes Protocol Checklist
www.nzgg.org.nz
Evaluating a Guideline
Patient education materials designed
for the Native American audience, which
may be useful for other populations
Evidence-Based Health Care Guideline
Implementation Study
www.tripdatabase.com
www.doh.wa.gov/ndep/wallet.htm
Why Don’t Physicians Follow Clinical
Practice Guidelines? A Framework for
Improvement
Michael D. Cabana; Cynthia S. Rand; Neil
R. Powe; Albert W. Wu; Modena H. Wilson;
Paul-André C. Abboud; Haya R. Rubin. JAMA.
1999;282:1458-1465.
ndep.nih.gov/materials/puborder/
resource.htm#people
www.qmnetwork.org
DIABETES TRAINING MANUAL
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Diabetes: List of Tools and Resources (continued)
Clinical Information System
Chart Abstraction Form
Diabetes Care Chart Audit
Registry Assessment Tool
Computer Assessment Tool
Electronic Registry
Sample Registry Report
Constructing a Registry
Definition of Homelessness
Health Care for the Homeless
Clinicians’ Network
615-226-2292
[email protected]
www.nhchc.org
The Unit for Evidence-Based Practice
Track II: National Tracking and Referral
Project for Migrating Patients with Diabetes
Migrant Clinicians Network
www.migrantclinician.org
DIABETES TRAINING MANUAL
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Diabetes: List of Tools and Resources (continued)
Delivery System Design
Conducting a Continuing Care Clinic:
Handbook for the Practice Team
Credentialing of Promotoras
fax: 956-447-0553
Diabetes Flow Sheet
ETHNIC: A Framework for Culturally
Competent Clinical Practice,
Organization Assessment Form
www.state.nj.us/health/bibs/education/ethnic.html
“Feet Can Last a Lifetime” Kit (2000),
National Diabetes Education Program
(includes ready-to-use exam forms,
patient education handouts, etc.)
ndep.nih.gov/materials/pubs/feet/feet.htm
Group Visit Starter Kit
Standing Orders
Training materials, e.g., Lower Extremity
Amputation Prevention (LEAP) Program
bphc.hrsa.gov/leap/
Planning Group Visits for High Risk Patients,
American Academy of Family Physicians
Words to the Wise, Bilingual Course
for Diabetes Promotoras, New Mexico
Department of Health Diabetes
Control Programs
www.aafp.org/fpm/20000600/33plan.html
505-827-2953
Sample Registry Report
Organization of Health Care
Business Case for Disease Management
www.improvingchroniccare.org
Care Model
www.improvingchroniccare.org
Changing Practice, Changing Lives:
The Health Disparities Collaboratives,
Training and Promotional Videos
www.healthdisparities.net
Improvement Model
Health Disparities Collaboratives Train-theTrainer Manual for Health Centers
DIABETES TRAINING MANUAL
72
Diabetes: List of Tools and Resources (continued)
Community
American Optometric Association,
Optometry Referral and Follow-up
800-262-3947
Americorps
www.americorps.org/
Bayer Corporation/Bayer Indigent
Patient Program
800-998-9180
Bristol-Myers Squibb Patient Assistance
Program
800-437-0994
Center for Disease Control and Prevention
www.cdc.gov/diabetes.
Culturally Appropriate Patient Education
Materials, Office of Minority Health
www.omhrc.gov/
Diabetes and Homelessness: Overcoming
Barriers to Care, Manual
www.nhchc.org/hot.html#diab.hot
Diabetes Today National Training Center
training and technical assistance on
applying a community mobilization model,
Diabetes Today
www.diabetestodayntc.org/
Eli Lilly & Company/Lilly Cares
800-545-6962
Hoechst Marion Roussel, Inc./Indigent
Patient Program
800-2114025
National Diabetes Education Program
800-438-5383 or ndep.nih.gov
National Diabetes Education Program,
Diabetes Community Partnership Guide,
page 51, “Organizations Making a
Difference with 18 Easy Ideas.”
ndep.nih.gov/materials/pubs/communityguide/community-guide.htm
National Eye Care Project Helpline,
No-Cost Ophthalmology Exam
NovoNordisk Pharmaceuticals Inc/
Indigent Program
800-727-6500
PCA Directory Listing
Pfizer Inc/Pfizer Prescription Assistance
State Based Programs to Reduce the
Burden of Diabetes
Summit Health Institute for Research and
Education (SHIRE), faith-based relationships
301-559-4400
Take Control of Diabetes Manual, Centers for
Disease Control and Prevention for Training
Community Health Workers (Spanish)
www.cdc.gov/diabetes/pubs/pubs.htm
Translation for Educational Materials:
www.freetranslations.com
www.systranet.com
1-800-222-EYES.
DIABETES TRAINING MANUAL
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