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1、Chronic care model toolsPam Allweiss MD, MPH (pca8cdc.gov) Consultant CDC Division of Diabetes Translation Faculty: University of KentuckyExamples of Tools, Checklists, Patient EducationSmall steps: Big rewards Cant transform everything at once Use the web sites to print out forms and “recipes” Dont
2、 re-invent the wheel Learn from othersExamples of Patient responsibilities checklist qExercise program qMonitoring of blood glucose q Adherence to the system of intensive self-management qAdherence to dietary guidelines qTreating and modifying “targets” in collaboration with physicianEndocrine pract
3、. 8:supl 1 2002Patient ResponsibilitiesqSmoking cessation qConsistent use of aspirin qOvercoming psychological and other barriers qHealthy expression of feelings q Foot and eye care qKnowledge of personal glycosylated hemoglobin value and its significanceEndocrine pract. 8:supl 1 2002Physician Respo
4、nsibilitiesq Measurement of outcomes q Development of evaluation programs; include safety in taking meds q Blood pressure monitoring q Determination of patient satisfaction q Maintenance of communication with team q Listening to patient concerns q Encouragement of patient in use of preventive measur
5、es q Record keeping and risk reductionEndocrine pract. 8:supl 1 2002Self-Management Support Tool HEALTHY CHANGES PLANq The healthy change I want to make is (very specific: What, When, How, Where, How Often): q My goal for the next month is: q The steps I will take to achieve my goal are: q The thing
6、s that could make it difficult to achieve my goal include: q My plan for overcoming these difficulties includes: q Support/resources I will need to achieve my goal include: q My confidence that I can achieve my goal: (scale of 1 -10 with 1 being not confident at all, 10 being extremely confident)www
7、.ihi.orgSelf Management Tools: Green Zone- Good HbA1c is under 7 Average blood sugars typically under 150 Most fasting blood sugars under 150 Your blood sugars are under control Continue taking your medications as ordered Continue routine blood glucose monitoring Follow healthy eating habits Keep al
8、l physician Tools Yellow Zone:Caution HbA1c between 7 and 9 Average blood sugar between 150-210 Most fasting blood glucose under 200 Work closely with your health care team if you are going into the YELLOW zone Your blood sugar may indicate that you need an adjustment of your medications Improve you
9、r eating habits Increase your activity level Call your physician, nurse, or diabetes educator if changes in your activity level or eating habits dont decrease your fasting blood sugar levels.Self Management Tool: Red Zone Red Zone: Stop and Think HbA1c greater than 9 Average blood sugars are over 21
10、0 Most fasting Blood sugars are well over 200 Call your physician if you are going into the RED zone Red Zone Means: You need to be evaluated by a physician. If you have a blood glucose over _, follow these instructions _ Call your physician Physician:_Summary Team approach Train everybody in your o
11、ffice Model is NOT just for diabetes, works for asthma, CVD etc Patients are hearing about group visits and like them (interaction with peers, like group therapy) Managed care is learning about group visits and likes themNational Diabetes Education Program Changing the Way Diabetes Is TreatedThree o
12、verarching campaignsNDEP educational materials Materials for the general public : Different ethnic background (African American, American Indian/Alaska Native, Hispanic/Latino, Asian American/ Pacific Islander) Many materials in English, Spanish and 15 Asian and Pacific Islander languages Different
13、ages (children, older adults)Also materials for Health care providers Community-based organizations Media outreach Working with business and managed careDiabetes Prevention: Small Steps. Big Rewards! Campaign focus: Prevent type 2 diabetes Modest lifestyle changes Lose 5-7% of body weight, 10-15 lbs
14、 in a 200 lb person Walk 30 minutes/5 days/ week Game Plan Tool kit: strategies to motivate patients to change lifestyleFor Health Care Providers: GAME PLAN ToolkitWalking Program GuideFood and Activity TrackerGAMEPLAN toolkitResourceshttp:/www.ihi.org: Institute for Healthcare Improvement, tools to
15、 print , “how to” manuals http:/: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc) http:/betterdiabetescare.org: info for practitionersResources http:/www.Improvingchroniccare.org Educational materials for patients http:/ http:/ http:/ndep.nih/gov http:/www/cdc/gov/team-ndep http:/www.diabetesatwork.org
