CCM element addressed | Number of practices | Description of a common intervention activity |
---|---|---|
Self management support | 16 | Provided patients with logbooks to track their HbA1c, BP and Lipid levels; patient education binders in exam rooms; diabetes education videos; āAsk me about Diabetes ABCsā buttons worn by staff; diabetes posters in exam rooms. |
Delivery system design | 8 | Group visits; re-organized clinic staff and delegated authority for testing/immunizations, etc.; began point-of-care HbA1c testing; |
Clinical information systems | 5 | Improved EMR functionality to provide individual and population level reports; diabetes flow sheets and/or templates in charts; |
Community linkages | 2 | Developed linkages for referral to nutritionist or for eye exams. |
Prepared proactive teams | ||
Initiated or increased staff meetings | 8 | Many practices had never met to discuss clinical improvement activities or at least met infrequently. Practice facilitators modeled effective meeting techniques and taught practices how to hold productive, effective team meetings. |
Initiated Huddles | 9 | Huddles are quick 3ā5 minute meetings of practice staff during the day for the purpose of planning for changes in workflow, anticipating and solving problems, and making adjustments to insure everyone is āon the same pageā. |