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COMMUNITY

The Diabetes Care Model Dr. Rosario Talavera, MSc. Consultant, PAHO/WHO II PAHO-DOTA Workshop on Quality Of Diabetes Care Diabetes Research Institute (DRI) University Of Miami, Miami 16 May 2003. The Diabetes Care Model. Organization of . ORGANIZATION OF . Community. COMMUNITY.

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COMMUNITY

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  1. The Diabetes Care ModelDr. Rosario Talavera, MSc.Consultant, PAHO/WHOII PAHO-DOTA Workshop on Quality Of Diabetes CareDiabetes Research Institute (DRI) University Of Miami, Miami16 May 2003

  2. The Diabetes Care Model Organization of ORGANIZATION OF Community COMMUNITY Diabetes Care DIABETES CARE Linkages LINKAGES Diabetes DM Self DM Self- Diabetes Information Resources Resources Management Management Information System Support Support System Policies Policies Delivery Delivery Decision System System Decision Support Design Design Support Prepared Informed Productive Activated Productive Diabetes Interaction Person with Team Diabetes Better health for people with diabetes II Workshop on Quality of Diabetes Care, Miami, May 2003

  3. Health Organization Critical elements • Coherent approach to system improvement. • Leadership committed for improving outcomes. • Incentives to HCP and pats to improve care. • Adhere to guidelines. II Workshop on Quality of Diabetes Care, Miami, May 2003

  4. Community Linkages Linkages are made to community resources • Resource directories • Referral paths • Joint programs: governmental and programs of community-based • Voluntary organizations II Workshop on Quality of Diabetes Care, Miami, May 2003

  5. Self-Management • Helps patients and families cope with the challenges of living with diabetes. • Minimizes/Delays complications. • Self-management programs rely on a collaborative process: patients and HCP. • Defines problems, sets priorities, establishes goals, creates treatment plans and solves problems. • Evidence-based educational training and psychosocial support interventions. II Workshop on Quality of Diabetes Care, Miami, May 2003

  6. Decision Support • Operates in accordance with evidence-based guidelines. • Supported by reminders. • Effective provider education. • Appropriate input. • Collaborative support from relevant specialties. II Workshop on Quality of Diabetes Care, Miami, May 2003

  7. Delivery System • Requires more than simply adding additional interventions. • Necessitates basic changes in system design. • Requires clear delegation of roles and responsibilities to the caring team (e.g. nurses, health educators, nutritionist, social worker). • Implies the use of planned visits. • Continuity of care and regular follow-up. II Workshop on Quality of Diabetes Care, Miami, May 2003

  8. Clinical Information • Information about individual patients & populations. • Diabetes is a critical feature of effective programs. • To establish a disease registry: Minimum data sets. • Health care teams access to a registry. • Call in patients with specific needs. • Planned care, can receive feedback & education. • Can implement reminder systems. II Workshop on Quality of Diabetes Care, Miami, May 2003

  9. II Workshop on Quality of Diabetes Care, Miami, May 2003

  10. Average of ACIC II Workshop on Quality of Diabetes Care, Miami, May 2003

  11. II Workshop on Quality of Diabetes Care, Miami, May 2003

  12. P-Values Team Self-Rating ACIC II Workshop on Quality of Diabetes Care, Miami, May 2003

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