You are here

Enhance Care Coordination

The Agency for Healthcare Research and Quality (AHRQ) has stated that the goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value healthcare.1 Care coordination has been recognized as a priority area by the Institute of Medicine,2 and is a tenet of many new payment and patient care models.

The American Diabetes Association recommends that care systems support team-based approaches to care and a patient-centered communication style to improve diabetes care.3

The educational and patient management resources offered below can help coordinate your efforts, and the efforts of your network providers, as you work towards improved care for patients with type 2 diabetes (T2D).

33 resources available

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.

care giver tips

Designed for people who are taking care of someone with T2D, this resource provides information and helpful tips.

Available in Spanish | Available in Mandarin

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.

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.

manager interview guide

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.

Briefly outlines physical activity and medical nutrition therapy recommendations, and offers tips to help patients make these important lifestyle changes.

Available in Spanish | Available in Mandarin

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.

T2D discharge planning

A step-by-step checklist of items to review and address prior to a patient’s discharge from the hospital.

Engaging Diabetes Patients about Common Comorbidities

Helps providers discuss the most common comorbidities related to T2D and how to engage patients using the teach-back method.

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.

T2D discharge medication list

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.

Reviews the issue of hypoglycemia in T2D and its associated complications, and includes a patient questionnaire.

Available in Spanish | Available in Mandarin

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.

Nutrition Tips for Managing Type 2 Diabetes

Offers patient tips on what to eat and combinations of food groups to avoid in developing a balanced and nutritious diet.
Available in Spanish | Available in Mandarin

Primary Care Physicians Obesity Management Strategies

Summarizes obesity-management strategies based on evidence-based clinical guidelines.

care coordination resource list

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.

Gives patients an introduction to potential members of the T2D healthcare team, along with a description of what they do and sample questions to ask of each. Includes room for the individual to write his or her own questions.

Available in Spanish | Available in Mandarin

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.

An overview of trends in the development and use of quality measures to enhance care of patients with diabetes.

Selection of tools and fact sheets for providers who are managing T2D patient populations.

Contains helpful resources for patients who are newly diagnosed with T2D.

Available in Spanish | Available in Mandarin

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.

Helps patients diagnosed with T2D share health information with their family/loved ones so others can begin to take steps to possibly reduce the risk of diabetes through proper food choices and appropriate physical activity.

Available in Spanish | Available in Mandarin

Family and Friends Education Guide for Type 2 Diabetes

Helps patients educate their family and friends on their commitment to a healthy lifestyle.
Available in Spanish | Available in Mandarin

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.

Available in Spanish | Available in Mandarin

Janssen tools and resources have not been proven to improve outcomes and may not completely address the specific intervention activities listed on each page. Janssen tools or resources discussed should be evaluated against other available sources of information before decisions are made about how to approach patient care within your organization. Full descriptions of appropriate use and associated limitations are set forth in the respective tools and resources.

CPT® is a registered trademark of the American Medical Association.

This information has been developed by Janssen Pharmaceuticals, Inc., and made widely available to support patient and provider education.


  1. Agency for Healthcare Research and Quality. Care coordination. Accessed December 14, 2017.
  2. Institute of Medicine. Priority areas for national action: transforming health care quality. Published January 7, 2003. Accessed December 14, 2017.
  3. American Diabetes Association. Executive summary: standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S5-S13.