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DSMT Toolkit

Chapter 6. The Role of Area Agencies on Aging and Community Partners in Providing DSMT Programs

Area Agencies on Aging (AAAs) are leaders in their communities, and many have developed relationships with health care providers, including those who can bill Medicare for DSMT services.

AAAs can receive participant referrals from health care providers, conduct the DSMT sessions, operate or collaborate to provide the infrastructure necessary to support an accredited program, and work with health care providers to maintain medical records and bill Medicare for payment. AAAs can also partner with health care providers by enrolling participants and marketing DSMT in community-based settings.

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Role of Partners

Community partners (stakeholders) are essential to improving healthcare delivery systems and increasing access to diabetes self-management programs. Partnerships with key stakeholders can lead to improved quality of and access to care and medical outcomes for persons who have diabetes.

Partners can:

  • Provide referral and education
  • Serve as strategic planners and policymakers
  • Use their leadership and communications skills to get the word out that DSMT saves lives
  • Volunteer to network and mentor people with diabetes
  • Work with diabetes organizations
  • Network with committed peers
  • Motivate and empower persons with diabetes to assume responsibility for the self-management of their diabetes
  • Serve as liaisons to the community
  • Assist with resources
  • Serve as Health Counselors
  • Provide services and goods to enhance a DSMT program

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Role of Health Care Providers

Health care providers and health care institutions also play a critical role in communities. Lifestyle change counseling conducted by health care providers, particularly physicians and dietitians, can help people lose excess weight, be physically active, maintain desired weight loss, etc.

Providers’ related interests are as follows:

  • Quality of community-based diabetes self-management education and training
  • Persons with diabetes and their implementation of self-care regimens
  • Achievement of targeted clinical outcomes and improved participant health
  • Achievement of recommended standards on diabetes, improved participant outcomes, greater professional satisfaction and patient satisfaction.

Community partnerships for providers are very important in leveraging limited resources. Providers can foster community partnerships by working with AAAs, local health departments, other health care providers, and various partners capable of providing or supporting programs that promote better diabetes self-management. CDEs can serve as effective bridges between primary and specialty care providers and community-based partners in the AAAs.

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Role of Federally Qualified Health Centers/Community Health Centers

Federally Qualified Health Centers (FQHCs) are local, non-profit, community-oriented health providers that provide high quality, affordable primary care and prevention services to vulnerable populations. FQHCs serve people who live in medically underserved areas. The main purpose of the Federally Quality Health Center (FQHC) Program is to enhance the provision of primary care services in underserved urban and rural communities.

While they have an overall mission to provide primary care services to vulnerable populations, regardless of insurance status, FQHCs often have substantial insured populations. So, FQHCs often serve large numbers of low-income Medicaid and Medicare patients. In addition, FQHCs receive increased reimbursement for serving vulnerable populations. As a safety net provider, FQHCs are often a key part of the community.

Partnerships between AAAs and FQHCs may be beneficial because FQHCs have an existing Medicare provider number and receive increased reimbursement when they do provide services for a Medicare beneficiary. This type of relationship can be mutually beneficial as it will provide the FQHC with access to another population of patients that they may not be serving. At the same time, the DSMT program would benefit by partnering with an established primary care provider with an existing billing system.

FQHCs provide the following preventive primary health services to Medicare beneficiaries:

  • nutritional assessment and referral,
  • preventive health education,
  • blood pressure measurement,
  • weight measurement,
  • physician examination targeted to risk,
  • visual acuity screening, and
  • cholesterol screening.

FQHCs also provide:

  • transportation,
  • translation,
  • health education,
  • disease management,
  • home visiting,
  • prevention services, and
  • outreach.

FQHCs provide linkages to community organizations for referral and other resources. FQHC-enabling services include patient education, translation/interpretation and community education.

Partnerships are essential to the success of an accredited DSMT program.

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