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DSMT Toolkit

Chapter 27: Sample AADE Application

Standard 9

The DSME entity will measure attainment of patient defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention.

Essential Elements Checklist:

  • Individual and aggregate achievement of behavior change goals
  • Policy required that outcomes data include appropriate measures
  • Reason for chose of outcome measures
  • Effectiveness of interventions is based on data

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Performance Measurement Plan/QI Plan (Standard 9):

The Diabetes Self-Management Training (DSMT) program will measure attainment of patient-defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of educational interventions. The performance measurement plan will commence upon the initial assessment between patient and PQI and may be augmented and modified during the 8-week intervention based on collaborative input from patient, PQI, and the multidisciplinary team.

Patient-defined Goals and Patient Outcomes

  1. Data Collection
    1. Individualized Data
      1. Participant-defined behavior change will be measured using individualized spreadsheets based on the AADE7 self-care behavior framework. This self-care framework is based upon the belief that behavior change can be most effectively achieved using the following 7 behaviors as a framework: healthy eating, being active, monitoring, taking mediation, problem solving, reducing risks and healthy coping. SMART goal sheets will be utilized for patient motivation and program documentation. The individualized spreadsheets will be linked to a global spreadsheet that tracks overall participant behavior change. The global database will be used to identify CQI measures and will be reported to the advisory committee at least annually.
      2. Long-term health outcomes measurement will be determined by guidance of the Diabetes Advisory Group and tracked individualized spreadsheets. Among these long-term health outcomes will be the measurement of mean hemoglobin A1C decrease and data collected will include, at a minimum:
        • Weight
        • Hemoglobin A1C
        • Medication Compliance
        • Age
        • BMI
      Each of the long-term outcomes measures will be stored in a database that captures data on each participant. The resulting data will provide the program coordinator with a data set to perform CQI. The results of this program data analysis will be reported to the advisory committee at least annually by the program coordinator.
    2. Aggregate Data
      1. Participant-defined behavior change will be measured using a database, based on the AADE7 self-care behavior framework.
      2. At least one long-term health outcomes measurement will be determined by guidance of the Diabetes Advisory Group based on influence of “Diabetes Self-Management Education Core Outcomes Measures,” Mulcahy, et al, Diabetes Educator, September/October 2003) and tracked using the participant outcome measures database.
  2. Frequency of Measurement
    1. Individual self-care behavior change data and selected health outcomes will be documented in the database at each patient encounter
    2. Individual self-care behavior change data will guide the education/training process. Program staff will have “read-only” access to the database to obtain participant level data and to run reports to determine trends.
  3. Evaluation
    Aggregate data will guide the Diabetes Advisory Group in determining CQI projects, annually. The Advisory group will define the outcome measures that they want to review and will submit these to the program coordinator to complete. The Advisory group will provide quality benchmarks for the program. Lastly, the Advisory group will work with the program coordinator to determine interventions to improve program quality benchmarks.

DSMT Support Plan Form (PDF, 71KB)

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Last Modified: 12/31/1600