STRATEGY* | DEFINITION | EXAMPLE |
---|---|---|
Electronic medical record | Electronic system for tracking patient appointments or for tracking specific patients with diabetes | NA |
Patient reminders | Telephone calls or postcards to patients to remind them of upcoming appointments or other aspects of diabetes management | Reminders of annual ophthalmology appointments |
Clinician reminders | Prompts to the health care provider to remind them of patient-specific diabetes management | Flag for patients who have not had recent HbA1c measurements recorded |
Audit and feedback | A summary of a physician’s clinical performance is sent to him or her for self-evaluation | Each month the physician receives the average of the most recent HbA1c values for each of his or her patients with diabetes |
Facilitated relay of patient data | Clinical information from patients that is transmitted to the physician via some other route than traditional medical interactions | Patient home glucometer readings are uploaded and e-mailed to case manager on a weekly basis |
Clinician education | Increasing physicians’ awareness of current practice guidelines and evidence-based recommendations | Conferences, workshops, educational outreach visits from PCN staff |
Patient education | Increasing patient understanding of disease pathophysiology and effective methods of secondary prevention | One-on-one counseling with nursing staff, group diabetes classes |
Promotion of self-management | Providing resources for patients to succeed in self-management | Glucometers, meal-tracking charts |
Team changes | Addition of 1 or more members to the health care team | Adding CDM nurses, dietitians, or pharmacists to the patient care team |
Case management | A team member other than the primary care physician assumes primary responsibility for coordinating care of patients with diabetes | Registered nurses track home glucose readings, send patients for bloodwork, and ensure that patients are seeing specialists appropriately |
CDM—chronic disease management, HbA1c—glycosylated hemoglobin A1c, NA—not applicable, PCN—primary care network.
↵* Strategy categories are taken from Shojania et al.23
Reprinted from Campbell et al.22