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From interviews with health centers and project officers, health centers that are performing well in the diabetes control measure engage in certain core activities, including:
- Ensuring complete and accurate documentation in the electronic health record to capture, in structured fields, data for the diabetes control and weight screening measures, foot and eye exams, and other relevant diabetes care information;
- Using patient data to develop a diabetes registry and gap list, identifying patients who need guideline-based tests and procedures or other specialized care;
- Following up with patients who are due or overdue for guideline-based care;
- Establishing a personalized diabetes management or action plan for each patient with pre-diabetes or a diabetes diagnosis;
- Providing education and support to patients and their families on lifestyle modifications and adherence tools, with the support of multidisciplinary team members, such as diabetes health educators, nurses, dieticians, community health workers, or clinical pharmacists;
- Addressing social risk factors by establishing partnerships with community based organizations, such as food pantries, farmers markets, and fitness programs.
Promising Practices
Here are some examples of innovative approaches health centers and a Primary Care Association are using to help patients prevent or control diabetes. Thank you to all of the organizations that shared their models. Please reach out to the contacts below to get more information.
Share Our Selves, Costa Mesa, CA
- Uses Medication Therapy Management (MTM) appointments, conducted by clinical pharmacists, to support patients with diabetes.
- MTM appointments help patients optimize medication lists, engage patients in medication management and lifestyle modifications, and decrease their risk of adverse medication events.
- Patients are encouraged to bring family members to these ongoing appointments to educate everyone in the household about the patient’s condition and how to achieve a healthier lifestyle.
Read the full promising practice.
Contact: Dr. Mary Ann Huntsman, Director of Clinical Pharmacy Services
Southcentral Foundation (SCF), Anchorage, AK
- Created a diabetes registry and action list that captures the preventive, screening, and disease/condition status of each provider’s panel of diabetes patients.
- Data drives quick action: if a customer-owner (patient) is identified as being due for a test or exam, SCF reaches out to him/her and makes a quick intervention.
- Community Health Aides provide care in remote areas; they are high school graduates who have received training to provide care by protocol, including diabetes management. Living and working in remote Alaskan communities, they are supported by distant site SCF physicians through telehealth.
- They follow up on the diabetes action lists with customer-owners in these locations, connecting them to specialty services using telehealth and coordinating health educator visits to these remote sites.
Read the full promising practice.
Contact: Brianne Gorham, M.A., Manager of HRSA grant (907)729-3250
Pennsylvania Association of Community Health Centers (PACHC)
- Spearheaded an effort to train Pennsylvania health center staff in diabetes prevention using lifestyle coach training.
- PACHC hosted a two-day training using the CDC lifestyle change curriculum. This program helps people who are at higher risk of developing diabetes adopt changes designed to reduce risk through measures such as diet and fitness.
- Participants also learned about CDC’s National Diabetes Prevention Program, which aims to reduce patients’ risk of type 2 diabetes.
- Participants were introduced to the Prevent Diabetes STAT toolkit and educational materials designed specifically for health care professionals by the CDC and the American Medical Association.
- PACHC recruited training participants by using UDS data to identify health centers with higher rates of uncontrolled diabetes among their patients.
Read the full promising practice.
Contact: Serina Gaston, Director of Strategic Initiatives & Corporate Compliance
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