Man Doing Blood Test

Diabetes & Social Determinants of Health

The 2020 National Diabetes Statistics Report has indicated that 34.2 million people, or 10.5% of the U.S. population, have diabetes.

 

The Diabetes and Social Determinants of Health Progression focuses on patients with diabetes and the impact that social determinants of health (SDOH) has on their overall care. Your pharmacy team can make a positive impact on the quality of life for your patients with diabetes through optimizing medication regimens and assisting with lifestyle changes. In turn, this makes a difference to payers and the cost of diabetes to the health care system. The progression aims to equip pharmacy staff members to identify and to close care gaps that are listed as standards of care in guidelines. The progression provides steps on how to document throughout the patient care process and implement opportunities to generate revenue related to diabetes services (e.g., immunizations, Diabetes Prevention Program, Diabetes Self-Management Education). One example of a step-wise approach to implementing these services is a diabetes checklist to assist with patient assessment and education of treatment goals, such as A1c and blood glucose measurements. The progression also provides information to identify SDOH in patients (e.g. food security, house stability, transportation access, financial stability) and reviews ways to address SDOH during the workflow process.

Source: Population Health and Social Determinants of Health in Diabetes Management

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Month 1 Change Package
Month 1 Change Package

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Month 2 Change Package
Month 2 Change Package

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Month 6 Change Package
Month 6 Change Package

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Month 1 Change Package
Month 1 Change Package

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Opioid Focus

Naloxone Guidance
Opioid Disposal & Deactivation
Pharmacists' Role in Opioid Stewardship
Guidelines
Patient Communication & Education
Opioid Tapering
Workflow Tools
eCare Plan Documentation

 

Immunizations

Workflow Tools
Vaccine Clinic Information
Immunization Schedules
eCare Plan Documentation
Records, Registries, and Reporting
Billing

 

Hypertension

Care Team Coordination
Guidelines
eCare Plan Documentation
Workflow Tools
Additional Information & Resources

Diabetes & Social Determinants of Health

Guidelines
Patient Communication & Education
Care Team Coordination
eCare Plan Documentation
Workflow Tools
Assessing Social Determinants of Health
Community Data & Local Services

Domains

 

Domain 1 : Leveraging the Appointment-Based Model

Domain 2 : Improving Patient Follow Up and Monitoring

 

Domain 3 : Developing New Roles for Non-Pharmacist Support Staff

 

Domain 4 : Optimizing the Utilization of Technology and electronic Care Plans 

 

Domain 5 : Establishing Working Relationships with other Care Team Members

 

Domain 6 : Developing the Business Model and Expressing Value

Guidelines

 

American Diabetes Association Standards of Medical Care in Diabetes – 2021 Living Standard

 

Identifying Gaps in Care Video

 

Addressing Gaps in Care Slides

 

Goals and Standards of Care for Patients with Diabetes

 

Diabetes & Social Determinants of Health - Goals of Therapy and Medications Video

 

Diabetes & Social Determinants of Health - Goals of Therapy and Medications Slides

 

ADA “Diabetes and Heart Disease” Handout

 

AHA CME Course: Measuring Blood Pressure Accurately - Step 1 in Hypertension Control

Patient Communication & Education

 

Introduction to Adherence Communication Coaching

 

NCPA Comprehensive Motivational Interviewing Training (comMIt)

 

ADA Patient Education Library Patient Handouts

Care Team Coordination

 

FtP Template Lab Request Letter

 

Prescriber Communication Template: Request Statin Use in Diabetes

 

Patient Adherence Summary Report Cards for Physicians

 

Pharmacist - Prescriber Collaboration Toolkit

 

Clinical Intervention Fax Template

 

Adherence Packaging Prescriber Communication

eCare Plan Documentation

 

Clinical Documentation and The Patient Record

 

Patient Encounter Documentation Form for eCare Planning - Diabetes

 

eCare Plan Documentation Guide: SNOMED CT Descriptions

Month 1 IZ/DM Persona & Sample Case

Workflow Tools

 

Electronic Quality Improvement Platform for Plans & Pharmacies (EQuIPP)

 

Diabetes Checklist for Patient Encounters

 

Med Sync Monthly Check-in Guide

 

Patient Blood Pressure Log

 

CLIA Certificate of Waiver Application Instructions

 

A1C Device & Cost Comparison

 

Social Determinants of Health Tracking Chart

 

Diabetes Prevention Program Presentation Video

 

Diabetes Prevention Program Presentation Slides

 

Diabetes Prevention in Pharmacies: Toolkit for Planning and Implementation

 

CDC Rx for the National Diabetes Prevention Program: Action Guide for Community Pharmacists

 

The Road to Diabetes Self Management & Accreditation Presentation Video

 

DSME Implementation Guide

 

Medicare Reimbursement for DSME

 

CDC’s Collaborative Practice Agreement Resource and Implementation
 

Guide for Pharmacists

 

Hypoglycemia Awareness Program Guide

 

Writing a Business Plan for a New Pharmacy Service

 

Plan-Do-Check-Act Cycle Project Planning Tool

Assessing Social Determinants of Health

 

CE: Population Health and Social Determinants of Health in Diabetes Management

 

CE: Community Health Workers in Community-Based Pharmacy Care Delivery

 

Community Health Workers in Community-Based Pharmacy Care Delivery Toolkit

 

Population Served and DSMES Service Assessment

 

PRAPARE®: Protocol for Responding to and Assessing Patient Assets, Risks, and Experien

 

The Accountable Health Communities Health-Related Social Needs Screening

 

CLEAR Toolkit

 

NCPA Annual 2020 Slides - How Can I Help my Patients with Social Determinants of Health in a Sustainable Way?

Community Data & Local Services

 

County Health Rankings & Roadmaps

 

Community Census Data

 

City Data

 

Community Resource Locator

 

Community Resource Guide Template

Find a Diabetes Education Program in Your Area

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OPIOID FOCUS

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IMMUNIZATIONS

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HYPERTENSION

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DIABETES & SOCIAL DETERMINANTS OF HEALTH

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