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DSMT Toolkit

Chapter 27: Sample AADE Application

Standard 7

An individual assessment and education plan will be developed collaboratively by the participant and instructor(s) to direct the selection of appropriate educational interventions and self- management support strategies. This assessment and education plan and the intervention and outcomes will be documented in the education record.

Essential Elements Checklist:

  • Collaborative participant assessment
  • Education process policy
  • Plan of care based on assessment and meets the individual’s needs
  • Integration of AADE7
  • Intervention per plan provided and outcomes evaluated
  • Collaborative development of education goal, objectives and plan

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The Professionally Qualified instructor is responsible for the overall delivery of course content. Each participant will have an initial assessment done by the professional instructor. At this time a customized education plan will be developed. The education plan will identify areas of need that are particular to the condition of the participant.

After the initial assessment, the participant will begin attending the group sessions. The group sessions provide general diabetes information about diabetes that is publicly available and the delivery of this information in the group setting is overseen by the professional instructor and is delivered by the community health workers. The professional instructor is always available to the CHWs and provides additional individualized instruction based on the education plan that was developed at the time of the initial assessment.

Each participant has subsequent individual educational sessions with the professional instructor, during the delivery of the course content. The frequency of the individual educational sessions is based on the clinical needs of the participant. The individual educational sessions provide an opportunity for the instructor to provide detailed clinical content that applies the general diabetes educational material to the specific clinical needs of the participant.

Most of the participants that complete the course will have a minimum of three (3) meetings with the professional instructor on an individual basis. These individualized educational sessions have an objective to deliver individualized instruction to the participant in a one-on-one setting with the professional instructor. However, the number of individualized sessions is dependent upon the clinical and educational needs of the participant and is at the discretion of the professional instructor that is leading the course.

The CHWs role is the deliver the general diabetes information content, under the supervision of the professional instructor. The general information is then reviewed with the participant in a manner that addresses their specific clinical presentation and educational needs as determined by the professional instructor and the education plan that is completed by the professional instructor.

The Professional instructor and CHWs work in a collaborative manner to address the educational needs of the participant by presenting each person with general diabetes educational content with individualized education sessions that are delivered by the professional instructor on a one-on-one basis. The professional instructor oversees the entire educational process, monitors the delivery of the general diabetes information, and provides individualized instruction based on the needs of the participant and documents the delivery of the educational content in the education plan.

Policy: Development of Individualized Education Plan and Physician Communication

(Standard 7)
An individual assessment and education plan will be developed collaboratively by participant and instructor(s) to direct the selection of appropriate education, interventions and self-management support strategies. This assessment and education plan and the intervention and outcomes will be documented in the education record. Please see enclosed curriculum.

REFERRAL AND MANAGEMENT

  1. Upon referral from their primary care provider or by self-referral, participants enter the program and receive consultation with a PQI. If an individual is a self-referral and does not have a primary care physician, he or she will be referred to a family practice physician in the Hebrew Senior Life system or an appropriate local system. The completion of an outpatient referral form is requested from the physicians, and includes diagnosis, complications, laboratory tests, current diabetes medication management, and other conditions. Participants are asked to complete an initial history, which includes demographics, medical information, nutrition and lifestyle facts and a psychosocial assessment. An appointment is then arranged for participants members to come to one of the diabetes education sites where they will meet individually with a PQI (RD or RN) and, where appropriate will be referred to additional individual and or group interventions. After each appointment, whether group or individual, the RN and the RD notify the physician of the visit through a progress note form. This form outlines education received, meal plans, activity/exercise plan, and participant&rsquos selected behavior change goals. An outcomes and educational objectives sheet is also completed by the second visit by the RN/RD. If phone contact is made with the patient between appointments, a chart note is written on the progress note form, with a copy going to the physician. If oral medication/insulin adjustments are recommended, a letter and physician order form is also sent to the referring physician.
  2. The basic education programs for Type 2 Diabetes, whether individually or in a group, consist of an initial consult and follow-up sessions as deemed appropriate. After the completion of the program at 8 weeks, patients are scheduled for follow-up sessions as needed annually or biannually. Follow-up appointment reminders may be provided in the form of a written postcard encouraging patients to come in for annual follow-ups. Phone call follow-ups may also be utilized if patients are unable to come in. Data collection spreadsheets will be used to determine when the patient is due for an annual follow-up appointment.

Various instructional approaches are used throughout individual and/or group sessions. Lecture, discussion, demonstration, return demonstration and educational materials handouts are utilized for all programs. If the patient has medical needs on follow-up that has not been taken care of with the patient&rsquos physician, this is addressed at this point. Any interventions are to be documented in the patient&rsquos chart in the progress notes with copies to the physician. The RD will also meet with each individual patient at the scheduled session times and review their meal plans, and various other aspects of nutritional counseling. If the participant fails to keep a follow-up appointment, he or she will be contacted with a letter indicating the appointment was missed and that continual follow-up is important in the self-management of diabetes. The participant is encouraged to reschedule. If the participant fails to do this within four weeks, the diabetes educator will call the participant to discuss achievement of behavior change goals and answer any questions the participant might have or address any difficulties in coming back for follow-up visits. After unsuccessful attempts to achieve compliance with the education plan by the diabetes educator, the participant is then considered “lost to follow-up” and it should be noted in the patient&rsquos record. A letter is also sent to the referring physician detailing each patient contact.

DSMT Intake Form (PDF, 117KB)

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