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Study results show medication adherence was inversely related to the number of prescribed doses per day, and that once-daily dosing is easier for patients and results in fewer dosing mistakes or missed doses.
Information about atrial fibrillation (AF) and stroke risk for healthcare professionals, which can be helpful in patient counseling.
Step-by-step checklist for review when considering transitioning patients from one site of care to the next, to help ensure that appropriate information is shared among healthcare professionals, patients, and their caregivers.
Reviews the types of barriers patients with T2D might face, and provides a series of assessment questions that can be used in building a care plan.
Suggested tools and resources that address specific treatment barriers that patients with T2D may face.
Promotes engagement by helping patients to keep track of their blood glucose measurements all in one place, and allows their HCPs to visualize trends and monitor progress.
Outlines the Agency for Healthcare Research and Quality’s key elements of delivering coordinated care for patients with complex needs (assessment, individualized care, access, and communication and monitoring) and how those elements may be applied to diabetes care.
A practical guide to the requirements for the Transitional Care Management services codes and Complex Care Coordination services CPT® codes.
An overview of key challenges in the management of patients with T2D, including information about how patients with T2D feel about their condition.
Advanced age and comorbidities increase the risk of AF or stroke and/or deep vein thrombosis/pulmonary embolism (DVT/PE) in the elderly; these and other complexities often make treatment decisions more challenging.
Reviews the drug and food interactions, fluctuations in international normalized ratio (INR) levels, and other attributes of warfarin use, including the possibility of hospitalizations that can lead to increased cost of care for patients.
Hypothetical look at AF patients and stroke risk when anticoagulant use is increased by 10%.
Tailored for a Latino audience, this patient education resource provides a brief overview of the connection between food and diabetes, discusses how carbohydrates impact blood glucose, and provides suggested smart food and carbohydrate choices.
Defines a patient-centered care approach and explains how it may be applied to diabetes care using the framework of the National Quality Strategy and its aim to foster improved care that is patient centered.
Offers recommended diabetes management practices including care coordination. Presents some of the many factors involved in diabetes care, and offers potential strategies to help case managers engage patients.
Based on the American Association of Diabetes Educators self-care behaviors, this interview guide can help case managers engage their patients with diabetes, and better understand their behaviors in order to promote individualized diabetes management.
The Diabetes Transitions of Care Kit provides tools and resources for providers/staff members who support care transitions for patients with T2D and multiple chronic conditions in hospitals/health systems.
Describes the Wells Clinical Prediction Rules and the Pulmonary Embolism Severity Index (PESI) score, which can help healthcare providers (HCPs) assess the risk of DVT or PE in their patients and determine the need for more definitive diagnostic testing.
An interactive resource guide to support improved care coordination for patients discharged after a DVT or PE.
Presents guidelines and recommendations from the American Diabetes Association that can serve as discussion points to help patients assess their level of engagement, and to track individualized goals and progress.
Helps providers discuss the most common comorbidities related to T2D and how to engage patients using the teach-back method.
Patient-oriented information about AF, including symptoms, stroke risk, and tips for working with their healthcare team.
Select performance measures and recommended guidelines for treating VTE and preventing recurrence.
This Medicaid best practice case study highlights the Health Partners of Philadelphia’s Healthier You Disease Management Program for Diabetes. Through multiple care coordination efforts, the program demonstrates improvements in select HEDIS diabetes measures.
Helps providers engage patients in a discussion of T2D self-management barriers and potential approaches to better manage them.
A reference list of all medications the patient is taking at the time of discharge, which can be shared with all healthcare professionals involved in their care.
Best practice case study highlights Keystone First’s goal to address poor A1C control in adult members with type 2 diabetes through a 12-week health education and awareness program. Measurable outcomes were achieved such as weight and cost-of-care reductions.
Facts about stroke risk in patients with AF, and a synopsis of guidelines for thromboprophylaxis.
Overview of VTE risk-reduction strategies at each stage of a knee or hip replacement procedure—from preoperative planning through the postdischarge period.
Tips about staying in good health for patients with diabetes, including the importance of maintaining a healthy weight, staying active, and controlling blood sugar, blood pressure, and cholesterol levels. Encourages patients to make regular visits to specialized healthcare team members, including optometrists and ophthalmologists, dentists, and podiatrists.
This Medicaid best practice case study highlights the Diabetes Control Network offered by Midwest Health Plan. Through frequent patient education, coordination, and outreach, the program demonstrates improvements in select HEDIS diabetes measures.
Introduces the methodology and concepts of motivational interviewing and how this technique may help patients with T2D.
Provides a brief set of motivational interviewing tips and techniques to help providers interview patients with T2D.
Summarizes obesity-management strategies based on evidence-based clinical guidelines.
Provides insights into the management of VTE patients and explains the role of the care manager in delivering effective follow-up care for these patients.
Provides insights into the health risks of patients with VTE and explains the role of the care manager in delivering effective follow-up care for these patients.
Clarifies how case managers can make a difference in effective VTE prophylaxis, and can serve as part of a comprehensive VTE prophylaxis program.
Describes VTE risk, from the perioperative and hospital phases to discharge and possible readmission, highlights potential intervention points and barriers, and suggests improvements for each phase.
Discusses guidance from the National Transitions of Care Coalition (NTOCC) and the Agency for Healthcare Research and Quality (AHRQ) on initial and ongoing follow-up as well as suggestions for encouraging patient adherence to their treatment protocols.
Offers case managers tips for preparing for a follow-up call to patients after knee or hip replacement surgery.
Presents the reasons why patients discontinue or are not-adherent with warfarin.
Overview of guideline recommendations for thromboprophylaxis and for effective care transitions.
A list of more in-depth information and links to online resources about care coordination for patients with T2D.
A background on T2D in the context of care coordination, including key strategies and opportunities for organizations to focus on to further improve diabetes care. Includes information from the American Diabetes Association and the AHRQ.
Helps patients understand why maintaining a healthy weight is important in T2D management and how excess weight often makes it harder to achieve successful treatment goals.
This employer and health plan collaboration best practice case study focuses on intensive chronic care management and patient-centered education and coordination. The results demonstrate improvements in clinical outcomes and reductions in healthcare costs for patients with diabetes.
Discusses health disparities in racial and ethnic minorities and the need to address cultural competence and individualized, patient-centric care.
Outlines the main goals of motivational interviewing, which follows established guidelines and techniques.
Provides suggestions for discharge planners and case managers should discuss with patients and their caregivers to support a successful transition from the hospital.
Selection of tools and fact sheets for providers who are managing T2D patient populations.
Features a questionnaire to help HCPs identify potential treatment barriers, and a map of available resources to help address them.
Specifically designed for people with T2D, this tracker lets patients keep all their important medical information, including information about their HCPs, together in a single place. Helps in establishing a complete medical record.
This commercial plan case study of UnitedHealthcare®'s Diabetes Health Plan highlights patient coaching, online monitoring, and benefit incentives as interventions to improve diabetes outcomes. The results demonstrate improvements in compliance to diabetes treatment and testing requirements such as blood sugar, cholesterol, and others.
Reviews the health implications and risks for patients with DVT and/or PE or AF who fall out of INR range as well as resource use and associated costs.
Illustrates each phase of the VTE prophylaxis flow (perioperative, hospital, discharge, and readmission) to prompt discussion about intervention points that support appropriate VTE prophylaxis.
Quick reference guide for patients with T2D. Discusses the importance of maintaining healthy blood sugar levels, and identifies strategies for managing blood sugar highs and lows.
Overview of AF, the warning signs of stroke, and tips for patients to work with their healthcare team. Can be provided as a newsletter to employees or health plan members.
Overview of the conditions, causes, and symptoms of DVT/PE and how to treat and potentially prevent a recurrent event. It also provides tips and tools to help patients adhere to their medication and track appointments, refills, and other health issues.
An overview of the healthcare professionals that encompass their treatment team, including primary care providers, certified diabetes educators, registered dietitians, endocrinologists, eye doctors, podiatrists, dentists, pharmacists, therapists, exercise physiologists, and case managers.