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
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 8

A personalized follow-up plan for ongoing self-management support will be developed by the participant and instructor(s}. The patient’s outcomes and goals and the plan for ongoing self-management support will be communicated to the referring provider.

Essential Elements Checklist:

  • Communication of educational services to physician / qualified non-physician practitioner
  • Policy for personalized process and ongoing self-management support strategies

Back to top

Policy: Follow up Plan (Standard 8)

A personalized follow-up plan for on-going self-management support will be developed collaboratively by the participant and multidisciplinary team led by the PQI. The patient&rsquos outcomes and goals, and the plan for on-going self-management support will be communicated to the referring provider.

At each follow-up visit, the participant meets with a RD or other diabetes educator who assesses the participant&rsquos current health status, knowledge, skills, attitudes and self-care behaviors. The blood glucose results are reviewed; quality control checks are done on the participant&rsquos blood glucose meters along with assessment of the patient&rsquos ability to perform their own blood glucose testing with their blood glucose meter. At this time behavior change goals are evaluated and, if needed, new goals are developed. The patient is given a copy of his behavior change goals. The RD or other diabetes educator also evaluates the patient&rsquos continuity of care to make sure all areas are being addressed appropriately. Outcomes are also measured by tracking the following clinical measures: Participant&rsquos HGB Ale testing results, Frequency of pre-and post-program participants obtaining an annual dilated eye exam, and Frequency of participants that obtain required foot screening.

The appropriate forms for eye care and foot care are filled out and sent to the referring physician. If the patient has medical needs on follow-up that have not been taken care of with the patient&rsquos referring physician, this is addressed at this point. Any interventions are to be documented in the patient&rsquos chart with a progress note with copies submitted to the referring physician. The RD will also meet with the 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 that the appointment was missed. The letter will highlight the importance of adhering to the recommended follow-up schedule as this in an integral part of the diabetes self-management learning process. The participant is encouraged to reschedule any missed appointments. If the participant fails to comply with the follow-up schedule 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 two phone calls from 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 documenting all care provided and attempts made to adhere to assist the participant with maintaining the follow-up schedule.

DSMT Follow-up Plan Form (PDF, 129KB)

Back to top

< previous | chapter list | standards list | next >