Learning Collaboratives:
Building an Effective Collaborative Care Team to Address Diabetes in Special and Vulnerable Populations: Tailoring Care for Social Context
This session focused on the necessary elements to develop a high functioning patient-centered team for diabetes prevention, management, and treatment in primary care. The session addressed the roles of all members of the team including the critical role of leadership and clinical champions to building an effective collaborative team. This session laid the groundwork for the full series by engaging participants in a discussion of how to tailor diabetes care for social context. The conversation focused on the key elements needed for treating diabetes in the primary care and community setting with an emphasis on team-based approaches to wellness.
Developing the Role of Community Health Workers and other Support Staff in Diabe- tes Prevention, Treatment, and Follow-Up
Community Health Workers (CHW) have been shown to be especially successful reaching hard to access populations such as agricultural workers and their families as well as the homeless and residents of public housing. In this session, participants and faculty explored the role of CHWs in the diabetes care team. Case studies and real-world discussion provided examples of both effective and ineffective integration of CHWs into the clinical care team. Participants discussed the scope of practice and most effective roles for CHWs within the diabetes care team as well as the role of clinical champions and leaders in effectively mobilizing the skills of CHWs and other team members.
Diabetes Continuum of Care: Using Behavioral Health and Substance Use Disorder Integration to Address Older Adults with Cognitive Impairments and Diabetes
Diabetes affects more than 30 million people in the United States. Multi-tiered efforts to prevent, treat and manage diabetes are critical in reducing the burden of diabetes, particularly for medically underserved racial and ethnic minority populations. In addition to higher prevalence, ethnic and racial minority patients with diabetes have higher mortality and higher rates of diabetic complications.
Identifying and Treating People with Prediabetes
Prediabetes is a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes. According to the Center for Disease Control and Prevention (CDC), approximately 84 million American adults—more than 1 out of 3—have prediabetes. Of those with prediabetes, 90% don’t know they have it. In this session participants discussed statistics of prediabetes and conversion rates from prediabetes to diabetes, identify patients at risk for diabetes, resources to screen and test for prediabetes and the use of EHRs to identify people with prediabetes.
Patient Engagement Strategies for the Collaborative Care Team: Group Visits
This session explored strategies and tools for diabetes pre-visit planning that can be successful for vulnerable populations. Participants and faculty brought case studies and real-life scenarios to the discussion in order to facilitate problem-solving conversations about how to address challenging scenarios. The session also addressed how to best incorporate pre-visit planning into a team-based setting that includes CHWs.
Phases of Diabetes Care
Diabetes care can be organized into three phases: pre-visit, intra-visit, and post-visit. Opportunities exist during each phase to introduce practice changes that can help engage and support patients in their diabetes care and management. Health care teams can optimize diabetes encounters by taking a planned, continuous improvement approach to visits, which includes pre-visit preparation (by both patients and practices), intravisit coordination (among practice team members), and post-visit follow-up (among the practice team and with patients).
Using Information Systems and Technology to Enhance Diabetes Care
Patients and physicians require new tools to manage the growing burden of chronic ill- ness. For providers responsible for the care of diabetic patients, developments in infor- mation management, real-time health education and feedback, and new approaches to self-monitoring and insulin delivery hold great promise to improve the quality and safety of diabetes care. In this call, NCHPH and Health Centers participants shared some of the major developments in the field, and the ways these technologies can be integrated into a typical practice.
Association of Health Literacy With Poor Diabetes Outcomes
The purpose of this session was to review the relationship between health literacy and health outcomes in patients with diabetes and discover what the potential interventions are to improve such outcomes.
Empowerment and Self-Management of Diabetes – The Pharmacist and Diabetes Care Learning Collaborative
The goal of this learning collaborative was to discuss with pharmacists how to integrate diabetes education and management into practice, so patients can make the best use of their medications and achieve the desired therapeutic outcomes.
The Impact of Nutrition on Diabetes Prevention and Diabetes Management
This presentation covered best practices for nutrition care, top eating patterns for people with diabetes, and ADA resources that can be used in practice.
Diabetes Continuum of Care: Impact of Health Literacy on Patients’ Diabetes Management and Self-Care
NCHPH partnered with members of the Special and Vulnerable Population Diabetes Task Force to provide a Learning Collaborative (LC) addressing critical issues to improve diabetes control in health centers nationally. NCHPH provided expertise in public housing primary care and provided a more in-depth exploration of strategies, tools, and resources needed to create positive change in diabetes control among health center patients. The LC sessions also provided in-depth knowledge and skills in order to address the unique needs of people experiencing homelessness, residents of public housing, migratory and seasonal agricultural workers, school-aged children, older adults, Asian Americans, Native Hawaiians and other Pacific Islanders, LGBT people, and other vulnerable populations.
Expanding Diabetes Prevention and Management Through Health Center Outreach This learning collaborative was comprised of a mix of outreach and diabetes educators from at least 10 health centers in or immediately accessible to public housing. Utilizing evidence-based models such as those developed by the Centers for Disease Control and Prevention (CDC), Community Preventive Services Task Force or National Health, Lung, and Blood Institute (NHLBI), the four learning modules allowed for the imple- mentation of process for weight screening and tracking patients with abnormal BMI and HbA1c.
To view more learning collaboratives, please visit our website at nchph.org