Recognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes. Register: Develop a registry for all of your patients with diabetes to track care. Resource: Support self-management through the use of interprofessional teams, which could include the primary care provider, diabetes educator, registered dietitian, nurse, pharmacist, specialists and self-management supports, including linkage to community services. Relay: Facilitate information sharing between the person with diabetes and the health-care team for coordinated care and timely management changes. Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.Conflict of interest statements can be found on page S33. Can J Diabetes 42 (2018) S27-S35
Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes. Diabetes care should be delivered using as many elements as possible of the chronic care model. The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including selfmanagement support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination. Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback.
HELPFUL HINTS BOX: ORGANIZATION OF CARERecognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.Register: Develop a registry for all of your patients with diabetes.Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists.Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes.Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.
This paper describes the Rhode Island Tobacco Control Enhancement Project (TCEP), a state-university-community technical assistance system. TCEP was developed under the auspices of the Rhode Island Department of Health's Tobacco Control program and was designed to build capacity among nine community-based organizations to mount comprehensive tobacco control interventions in five diverse communities within the state. This paper: (1) provides a description of community mobilization; (2) presents a logic model for planning and decision making used by state-university-community partners; (3) describes training, technical assistance services and implementation; and, (4) describes the evaluation and program improvement activities used to support on-going project development.
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