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BI-DIRECTIONAL REFERRAL SYSTEM


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BI-DIRECTIONAL REFERRAL SYSTEM

STRATEGY LIST

1305 Basic

Strategy 7: Promote participation in ADA-recognized, AADE-accredited, state-accredited/certified, and/or Stanford licensed diabetes self-management education (DSME) programs (See also Self-Management)

Performance Measure B.7.01

Proportion of people with diabetes in targeted settings who have at least one encounter at an ADA-recognized, AADE-accredited, state accredited/certified, and/or Stanford licensed DSME program


The purpose of this performance measure is to measure the number of encounters that people with diabetes have at DSME programs. Diabetes self-management education (DSME) offered in community gathering places is effective in improving glycemic control for adults with type 2 diabetes (Norris et al., 2002). Participation in diabetes self-management education is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services (Duncan 2009). Increasing the number of encounters that people with diabetes have at DSME programs in clinic and community settings increases the likelihood of improved health outcomes.

1305 Enhanced

Strategy 1: Increase use of diabetes self-management programs in community settings

Intervention: Increase access, participation/referrals, and reimbursement for AADE-accredited, ADA-recognized, State-accredited/certified, or Stanford-licensed DSME/T programs (See also Self-Management)

Intermediate:

Performance Measure 4.1.06

Proportion of people with diabetes in targeted settings who have at least one encounter at an ADA recognized, AADE accredited, state accredited/certified, and/or Stanford licensed DSME program during the funding year


The purpose of this performance measure is to measure the number of encounters that people with diabetes have at DSME programs. Diabetes self-management education (DSME) offered in community gathering places is effective in improving glycemic control for adults with type 2 diabetes (Norris et al., 2002). Participation in diabetes self-management education is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services (Duncan 2009). Increasing the number of encounters that people with diabetes have at DSME programs in clinic and community settings increases the likelihood of improved health outcomes.

Strategy 2: Increase use of lifestyle intervention programs in community settings for the primary prevention of type 2 diabetes

Intervention: Increase referrals to, use of, and/or reimbursement for CDC-recognized lifestyle change programs for the prevention of type 2 diabetes (See also Diabetes Prevention)

Short-term:

Performance Measure 4.2.01

Proportion of health care systems with policies or practices to refer persons with prediabetes or at high risk for type 2 diabetes to a CDC-recognized lifestyle change program


The purpose of this performance measure is to look at health care systems that have policies or practices to refer persons with prediabetes or at high risk for type 2 diabetes to a CDC-recognized lifestyle change program. The recognition program requires that a minimum of 50% of program's participants must have had a recent (within the past year), documented, blood-based diagnostic test indicating they have prediabetes, or a history of gestational diabetes mellitus (GDM), according to one of the following specifications:

  1. Fasting plasma glucose of 100 to 125 mg/dl
  2. Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  3. A1c of 5.7 to 6.4
  4. Clinically diagnosed GDM during a previous pregnancy (may be self-reported)

Performance Measure 4.2.02

Proportion of participants in CDC-recognized lifestyle change programs who were referred by a health care provider


The purpose of this performance measure is to assess grantee efforts to: 1) increase the number of health care providers referring people with prediabetes or at high risk for type 2 diabetes to a CDC recognized lifestyle change program, and 2) increase the number of participants who were referred by a health care provider. One of the standards for CDC recognition is that a minimum of 50% of a program’s participants must have had a recent (within the past year), documented, blood-based diagnostic test indicating they have prediabetes or a history of gestational diabetes mellitus (GDM), according to one of the following specifications:

  1. Fasting plasma glucose of 100 to 125 mg/dl
  2. Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  3. A1c of 5.7 to 6.4
  4. Clinically diagnosed GDM during a previous pregnancy (may be self-reported)

Intermediate:

Performance Measure 4.2.04

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC-recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes (The CDC's National Diabetes Prevention Program).

1422 Component 2

Strategy 2.8: Implement systems and increase partnerships to facilitate bi-directional referral between community resources and health systems, including lifestyle change programs (e.g. EHRs, 800 numbers, 211 referral systems, etc.)(See also Diabetes Prevention)

Short-term:

Performance Measure 20A

Number of health care systems with an implemented community referral system for evidence-based lifestyle change programs for people with hypertension


The purpose of this performance measure is to assess the increase in the number of health care systems that have implemented a referral system to evidence-based lifestyle change programs for people identified with high blood pressure. Ideally, the referral system will be integrated with an EHR system and will facilitate electronic bidirectional feedback between the evidence-based lifestyle program and the health care system (e-referral system). A bidirectional process considers both the information going from the health care system to the evidence-based lifestyle change program and the information returning from that program to the health care system.

Performance Measure 20B

Number of health care systems with an implemented community referral system to CDC recognized lifestyle change programs for people with prediabetes


The purpose of this performance measure is to assess the increase in the number of health care systems that have implemented a referral system to CDC recognized lifestyle change programs for people identified with prediabetes. (See performance measure 17B.) Ideally, the referral system will be integrated with an EHR system and will facilitate electronic bidirectional feedback between the CDC recognized lifestyle program and the health care system (e-referral system.) A bidirectional process considers both the information going from the health care system to the CDC recognized lifestyle change program and the information returning from that program to the health care system.

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Performance Measure 26

Number of persons with high blood pressure who enroll in an evidence-based lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people with high blood pressure enrolled in an evidence-based lifestyle change program. High blood pressure is one of the leading causes of heart disease and stroke. One in 3 U.S. adults has high blood pressure, and half of these individuals do not have their condition under control (Million Hearts, 2015). Persons with high blood pressure are often encouraged to take steps (i.e., lifestyle changes) to lower and control their blood pressure, including eating a healthier diet, managing their weight and increasing physical activity. In addition, clinical studies have demonstrated that participating in an evidence-based lifestyle change program can help control blood pressure in persons with hypertension, thus decreasing their risks for heart disease and stroke.