Toolkit
This is a collection of specific items that were particularly useful in the delivery of community based diabetes care. Most of these tools have an active link back to the program that used them in the Site Reports section.
Program Tools
These are specific tools used that can be applied directly at the program level.
Physician Flow Sheet — This is the document the primary care physician reviews each time he meets with a diabetic patient. Most programs develop their own flow sheets with direct input from the physicians involved. This is a sample from the Vermont Diabetes Information System.
Core Measures for Diabetes Patients — This ten-page document contains the Health Disparities Collaboratives (HDC) Diabetes Collaborative Phase 1 Measures from 2006, along with: the patient selection criteria; definitions of the Measures; the data gathering plan; the goals; any relevant notes/comments about the Measures; as well as a list of references.
Lab Value Alert Letter — Current laboratory results can be used to trigger specific alerts to patients that their test results exceed a guideline-based threshold. This is a sample alert letter from the Vermont Diabetes Information System used to engage and motivate patients and to improve the interaction with their doctor.
Reminder Letter — Reminders are a standard practice to improve consumer's adherence to treatment. This is a sample reminder letter from the Vermont Diabetes Information System.
Risk Stratification — The potential health care expense of diabetic patients is directly related to the degree of glycemic control. Uncontrolled diabetics with high HA1c values are the most expensive and expensive interventions will still produce a positive return on investment (ROI). Diabetics with their disease under control do not require the same level of intervention. This is a sample Risk Stratification table from the Savannah Business Group on Health that shows what interventions are provided to diabetic patients at three different levels of control.
Physician Incentive Structure — This is a sample chart showing the incentive payment calculation method from the Savannah Business Group on Health's diabetes Physician Pay for Performance program.
Expectations for Diabetes Care — An example of how to apply the Chronic Care Model with specific change concepts for diabetes care at the practice level.
Organizational Tools
These are tools useful for business coalitions in the process of establishing programs.
Diabetes Guide for Policymakers — This was developed by the Agency for Healthcare Research and Quality to facilitate the spread of effective diabetes treatment programs.
National Health Quality Report 2006 — The current report by the Agency for Healthcare Research and Quality on progress in quality improvement across major categories of health care. The Diabetes section begins on page 32.
State of Diabetes in America — The report by the American Association of Clinical Endocrinologists on the status of diabetes care.
Chronic Care Model — Brief summary of the Chronic Care Model elements.
Diabetes Self-Management Program — There are many successful programs that provide 12-15 hours of material in multiple sessions. Most large hospitals provide this information at their facility in two or three sessions. Other programs are available that provide it in one or two hour sessions at the worksite. Two programs that use shorter sessions at non-hospital locations are:
Existing Diabetes Management Programs — There are several successful programs for employers working to reduce the impact of diabetes in their workforce. Some are general disease management programs covering multiple diseases and others are focused on diabetes. Some of the most widely known examples are:
|
