Sustainable Strategies for Diabetes Self Management
Improving Diabetes Prevention and Management
November 15, 2007
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The prevalence of diabetes in adults in New York State’s Adirondack region is disproportionately higher than the State’s overall rate. The percentage of adults who reported receiving an HbA1c test in the region is also significantly lower than the statewide average. Glens Falls Hospital, a community hospital with multiple primary care practice sites in the Adirondack region, sought to address these issues through its diabetes registry project. The intent of this project was to implement a Web-based diabetes registry at six of its twelve primary care sites to increase the efficiency and effectiveness of care provided to its patients with diabetes. It also planned to develop a menu of resources and support programs to help patients self-manage their condition. The New York Health Foundation funded this project through its 2007 Setting the Standard: Advancing Best Practices in Diabetes Management request for proposals.
Project plans include implementing a disease registry in eight primary care practices. This system will include patient and physician reminders that will help providers prepare for office visits and will allow evaluation of physician performance based on the American Diabetes Association’s national standards. The project includes redesigning office visits to make them more coordinated for diabetes patients (involving a medical doctor, registered nurse, diabetes educator, and medical assistant team) and integrating a depression screening tool for diabetes patients. Patients identified with symptoms of depression will be referred to a behavioral health provider at Glens Falls Hospital and will be invited to participate in existing support groups for patients with depression and chronic conditions. Glens Falls will conduct patient focus groups and use the results to revise and inform self-management strategies. Glens Falls will use its longstanding relationships with community organizations (including libraries, school nurses, and volunteers) to extend efforts to promote nutrition and physical activity throughout the region.