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Home > Disease Management
Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change
Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change
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What's working in diabetes management?

According to market research conducted by the Healthcare Intelligence Network, disease-specific strategies that mobilize certified diabetes educators (CDEs), case managers and health coaches to foster self-management in individuals with diabetes are garnering the richest returns.

Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change takes an in-depth look at three patient-centered programs for diabetes management that are improving clinical outcomes and bending the cost curve for program participants.

Beginning with an overview of the latest trends in diabetes management, this 55-page special report goes on to examine the program components, staffing requirements, challenges, health and financial outcomes and ROI of the following initiatives:

  • The diabetes medical home approach at the heart of the Hudson River HealthCare (HRHC) Diabetes Collaborative, a network of 16 federally qualified health centers (FQHCs) located across six counties in New York's Hudson Valley.

    Kathy Brieger, RD, CD, HRHC chief operations officer, describes results achieved by the 12-year-old collaborative's team of physicians, nurse practitioners, physician assistants, RNs, LPNs, medical assistants (MAs), certified diabetes educators, nutritionists and community health workers (Patient Care Partners) working to manage diabetic care for 3,400 patients.

  • A comprehensive diabetes education program in place at Main Line Health System that deploys a team of CDEs and registered dietitians across four hospitals to provide multi-tiered levels of education to patients with diabetes.

    In a Q&A interview, Janet Wendle, RN, CDE, system director of the Main Line Health Diabetes Management program, describes the typical 10-hour education program offered to each participant and the satellite efforts that support it. She also discusses the challenges of patient follow-up, and Main Line Health's outreach to two important populations: patients with pre-diabetes and women with gestational diabetes.

    Main Line Health System was a respondent to HIN's 2011 Survey on Diabetes Management.

  • Health outcomes and ROI achieved by Alere Health Nurse Coaches who work telephonically to provide diabetic patients with information, motivation and behavioral skills (IMB).

    In an extended interview, Gordon Norman, MD, MBA, chief innovation officer for Alere Health, details the multi-faceted program in which 350 RN nurse coaches provide telephonic support to 46,000 individuals across all diabetes acuity levels. According to an article in the July 2010 issue of The American Journal of Managed Care, Alere's diabetes management program for a Medicare Advantage population with comorbid diabetes and coronary artery disease (CAD) was effective in reducing hospital inpatient admissions and total costs.

    Alere Health was a respondent to HIN's 2011 Survey on Diabetes Management.

The programs profiled in Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change reflect the most current strategies to rein in healthcare costs and utilization associated with diabetes: a patient-centered medical home approach, diabetes education and behavior modification.

This resource provides details on the following:

  • How each program is addressing weight management, identified as the greatest challenge in the control of diabetes;
  • Staffing considerations, case loads and training for diabetes management programs;
  • Engaging the primary care physician in diabetes management;
  • Tweaking a diabetes education program to meet the needs of specific populations;
  • Planning events to support and encourage patients and health plan members in the management of their disease;
  • Clinical and financial outcomes from each approach;
  • Future program expansion;
and much more.

Table of Contents

  • Introduction: 2012 Benchmarks in Diabetes Management
    • Survey Highlights
    • Key Findings
    • About the Survey
    • Respondent Demographics
  • HRHC Diabetes Collaborative: Lessons from a Patient-Centered Medical Home Approach
    • A Look at Hudson River HealthCare
    • Birth of the HRHC Diabetes Collaborative
    • Standards in the Enhanced Care Model
    • Self-Management Support for Individuals with Diabetes
    • Tracking and Coordinating Care
    • Outcomes and Results from the Intervention
    • HRHC Staff Training Institutes
    • Focus on Diabetes Instruction
  • Main Line Health Diabetes Management Program: Tailoring Education to Population Needs
    • Respondent Snapshot Main Line Health System Diabetes Management Program
    • Program Description
  • Alere Health Nurse Coaches Support Patients Telephonically with Information, Motivation and Behavioral Skills
    • Respondent Snapshot Alere Health Nurse Coaches
    • Program Description
  • Q&A: Ask the Experts
    • Building Patient Buy-In
    • Activating the Disengaged Patient
    • Tools to Assess Care Coordination Levels
    • Site Quality Reports
    • Integrating Oral Health Needs into Team-Based Care
    • Using a Diabetes Registry
    • Addressing Behavioral Health
    • Impact of Diabetes Collaborative on Readmissions
  • Glossary
  • For More Information
  • About the Presenters

2011 data from the American Association of Diabetes indicate that 25.8 million children and adults in the United States 8.3 percent of the population have diabetes. The total cost of diagnosed diabetes in the United States in 2007 amounted to $174 billion. Adults with diabetes are more likely to have strokes and heart disease than those without diabetes.

Publication Date: July 2012
Number of Pages: 55
ISBN 10: 1-937229-81-5 (Print version); 1-937229-82-3 (PDF version)
ISBN 13: 978-1-937229-81-8 (Print version); 978-1-937229-82-5 (PDF version)
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