Skip Navigation
Link to HHS Website Department of Health & Human Services
 
Link to Administration on Aging HomePage
  Home > AoA Programs > Health, Prevention, and Wellness Program
Home
About AoA
Press Room
Elders & Families
Emergency Preparedness
Aging Statistics
AoA Programs
Program Results
Grant Opportunities
AoA Funded Resource Centers
              

DSMT Toolkit

Chapter 27: Sample AADE Application

Standard 6

A written curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, will serve as the frame work for the DSME program. Assessed needs of the individual with pre-diabetes or diabetes will determine which of the content areas listed below are to be provided.

Essential Elements Checklist:

  • A written curriculum tailored to meet the needs of the target population
  • Adopts principles of AADE7 and includes disease content
  • Curriculum is kept updated reflecting current evidence and practice guidelines and is culturally appropriate
  • Curriculum maximized use of interactive training methods

Back to top

DSMT Curriculum:

The Eight (8) week DSMT curriculum set forth below is designed to provide each participant with an individual assessment and education plan that has been developed collaboratively by participant and instructor{s) to direct the selection of appropriate education, interventions and self-management support strategies.

Week 1

Individual Assessment with Registered Dietitian or Registered Nurse (PQI): Each new participant will undergo a 1:1 in person assessment with either a Registered Dietitian, or Registered Nurse with particular training in diabetes. The assessment will include information about the individual’s relevant medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, self- management skills and behaviors, readiness to learn, health literacy level, physical limitations, family support, and financial status. The current assessment tool is attached hereto and subject to modification as part of our ongoing quality improvement efforts. During this assessment, educational goal/s, and learning objectives and the plan for educational content and method/s will be developed collaboratively between the participant and instructor{s). This plan will include, where appropriate, ongoing assessment with the Registered Dietitian, or Registered Nurse and/or referral to the Stanford Diabetes Self-management program (Standard 7).

During the initial assessment, any additional participant needs that are identified by the participant, in collaboration with the PQI, will be addressed outside of the Stanford Class individually, but will be an integral part of the entire DSMT process. This plan will also include a personalized follow up plan (Standard 8) for ongoing self-management support, which will be developed collaboratively by the participant and instructor (s). The patient’s outcomes and goals and the plan for ongoing self-management support will be communicated and documented. These outcomes and goals may be distinct and in addition to the goal or "action plan" participants develop in the Stanford DSMP program as discussed below. The follow-up plan for ongoing self-management support will focus on long-term self- management that occurs after the Stanford DSMP class ends. Also during this assessment, participant is provided a copy of the attached pamphlet entitled, "Healthy Living with Diabetes: A guide for adults 55 and up" published by the American Diabetes Association. PQI reviews relevant information in the pamphlet, consistent with the assessment, and attaches his/her contact information (telephone and email) to the pamphlet with an invitation for participant to contact PQI with any follow up questions or concerns.

For participants with vision limitations, a card magnifier is provided.

In accordance with Standard 9, the PQI will continue discussions with the participant during the eight-week intervention no fewer than twice in an effort to measure attainment of patient-defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention. The assessment and any follow-up documentation will be provided by the PQI to the PCP and the PQI will be available to discuss the assessment and plan with the PCP.

PQI and group leaders will further engage in regular communication with one another during the six week Stanford intervention to ensure that the participant’s plan is appropriate and to address any challenges, questions, lack of information, or other support the participant may need from either the PQI, primary care provider or another professional. The PQI will document regularly all communication with group leaders.

Back to top

Weeks 2, 3, 4, 5, 6 and/or 7

In accordance with Standard 9, the PQI will continue discussions with the participant during the eight week intervention no fewer than twice during Weeks 2–7: The Stanford DSMP class is the base curriculum for our DSMT service. During this six (6) week workshop, participants will be provided with an array of tools to improve their ability to self-manage their conditions. The Stanford DSMP class is the primary intervention, to fulfill the participant’s need for improved diabetes self-management, but will not be the only intervention and will be coupled with the individualized education plan developed collaboratively based on the initial assessment. The Stanford DSMP class is provided by group leaders, under the supervision of the PQI and includes discussion of all relevant AADE diabetes education benchmarks, including but not limited to the following: overview of diabetes, blood glucose monitoring, nutrition, preventing high and low blood sugar, preventing or delaying complications from diabetes, physical activity, dealing with stress, muscle relaxation, reading nutrition labels, depression management, communication with health care providers, medication usage, foot care, working with the health care system, and planning for the future. The program also requires participants to continue to set individualized weekly goals or “action plans” and to provide follow-up for each action plan achieved. For action plans not achieved, participant engages in problem solving activities with the group to brainstorm potential solutions. At the beginning of each week 2&ndsah;7, the PQI sends a detailed email to the group leaders outlining the anticipated activities for the week, as well as the availability of the PQI before, during or after sessions. Texts of each email are attached hereto in a Word Document entitled "PQI Communications". The PQI remains available to both the Group Leaders and the Participant to measure attainment of patient-defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention. The primary goal is an improvement in the person’s self-management behaviors. Outcomes will be compared to quality indicators to assess the effectiveness of the patents’ care plan and the education intervention. Both individualized and aggregate outcomes data will be collected and will include, at a minimum, the following: attainment of participant-defined behavior change goal(s) (intermediate outcomes) and at least one post-intermediate or long term health outcome measure. In a collaborative manner the participant and PQI will define the individualized goals. These individual patient outcome measures are used to guide the intervention and improve care for that participant. The aggregate population outcome measures (program outcome measures) are used to guide programmatic services and CQI activities for the DSME and the population it serves.

During this time period, the success of the Stanford DSMP intervention in meeting the participant’s defined goals is measured by the participant’s ability to set weekly measurable goals and report back on attainment of these weekly goals in a group setting, with peer involvement. Documentation of the attainment of this goal will be class attendance and participation in the weekly goal setting process with the peer group. Other goals outside of improved self-management behaviors will be addressed as part of the individualized plan and will occur outside of the Stanford DSMP, but remain part of the entire DSMT program and will be directed by the PQI in collaboration with the participant. Methods of attaining these other goals are decided by the participant in collaboration with the PQI. Documentation of class participation, weekly goal setting, and individualized assessment will be maintained in the participant’s chart.

Back to top

Week 8

At the end of the Stanford DSMP intervention, the participant will develop a follow-up plan in a collaborative manner with the PQI. There will be a multidisciplinary approach to completing this process. The multi-disciplinary team works with the participant to develop realistic, individualized goals and an ongoing evaluation plan. The multi-disciplinary team will consists of, at a minimum, the following: PQI, group leaders delivering the Stanford DSMP classes, and participant’s primary care provider. Long-term evaluation can include things such as improved HgbA1C values, improved fasting glucose values, improved lipid levels, increased frequency of physical activity, and improved dietary intake. These long- term goals and follow-up should be documented in the participant’s record. Resources to support the attainment of these goals will be identified in a collaborative manner. The goals for ongoing self-management, support resources, and ongoing evaluation plan must be communicated to the referring provider. The communication with the referring provider will be documented in the participant’s record.

Example of Diabetes Self-Management Program Leader's Manual Session One Page 5, Workshop Overview sheet with chart 2 categories filled out for Weeks 1-6

Back to top

Workshop Overview—Activity Session 1 Session 2 Session 3 Session 4 Session 5 Session 6
Overview of self-management and diabetes
—Reducing Risk
x          
Making an action plan
—Reducing Risk
x x x x x x
Monitoring
—Monitoring
x x x x x x
Nutrition/Healthy Eating
—Healthy Eating
x x x x    
Feedback/problem-solving
—Problem Solving
  x x x x x
Preventing low blood sugar
-Reducing Risk
  x        
Preventing complications
—Reducing Risk
    x      
Fitness/exercise
-Being Active
    x x    
Stress management
-Healthy coping
    x      
Relaxation techniques-
—Healthy coping
    x x    
Difficult emotions
-Healthy coping
      x    
Monitoring blood sugar
-Monitoring
        x  
Depression
-Healthy coping
        x  
Positive thinking
-Healthy coping
        x  
Communication
-Healthy coping
        x  
Medication
-Taking medication
        x  
Working with healthcare professional
-Reducing Risk
          x
Working with healthcare system
-Reducing Risk
          x
Sick days
-Healthy coping
          x
Skin and foot care
-Monitoring
          x
Future plans
-Reducing Risk
          x

Back to top

< previous | chapter list | standards list | next >