The management of patients with diabetes, like other chronic conditions, is complicated, requiring care that addresses medical, social and behavioral aspects of individuals, along with pro-active population management. Poorly controlled diabetes can lead to multiple complications, poor health outcomes, and reduced quality of life. At least one out of every seven health center patients has a diagnosis of diabetes.
Given the prevalence of diabetes among health center patients, the impact that poor control has on quality of life, health outcomes, mortality, and costs, and the positive outcomes that can result from improved diabetes management, the National Association of Community Health Center’s (NACHC) project, Improve Diabetes Care in Health Centers, developed a preliminary change package for diabetes prevention and management. This toolkit is a working document that offers tools, strategies, and interventions for health centers to transform their diabetes-related care processes and outcomes. It offers five evidence-based interventions for each of the three HRSA technical assistance strategy areas, along with specific actions, tools and resources for each intervention and action steps.
National Nurse-Led Care Consortium engaged 10 nurse-led health clinics from across the country to participate in a rapid cycle, 13 weeks learning collaborative in which to explore 3 of the 15 strategies outlined in NACHC’s change package: Care Team Formation, Pre-visit Planning and Patient Education and Engagement. Each of these 3 topics was presented in a coupled section comprised of a 90 minute training session followed two weeks later with a 30 minute facilitation session with the focus on participants’ transformation work or “tests of change.” This provided opportunity to engage in both a didactic experience as well as peer collaboration and sharing. Each session gave time to check in, discuss how the activities were going and to share any practice insights and recommendations with participants.