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September 23, 2018

Heatlhcare Provider Resources

Because the U.S. health system is going through major transformations, it is more critical than ever that the Idaho Heart Disease and Stroke Prevention Program (HDSP) continue to create connections with Idaho healthcare providers, particularly those working in Primary Care. The resources included on this page address hypertension, heart disease, stroke prevention and co-morbid conditions like diabetes and prediabetes.  The HDSP and the Idaho Diabetes Prevention and Control Program (DPCP) work closely together to educate the public and work with health systems to provide evidence-based and best-practice resources that improve the delivery of care, and ultimately the health outcomes for Idahoans. We welcome your input to help us make a difference in the lives of your patients and we hope that the resources provided here are useful and timely.

Hypertension Control Toolkits and Guidelines

Quality Improvement

Continuous quality improvement (CQI) is a term frequently used in healthcare and public health. Regularly reviewing data and engaging in deliberate quality improvement activities are important steps to increasing the control rates for hypertension and diabetes for patient populations.  Below are some resources for integrating quality improvement activities. 

Toolkit's and Guides

Health Resources and Services Administration (HRSA) Hypertension Control Toolkit

Institute for Healthcare Improvement: Provides information and tools for quality improvement projects.

Minnesota Quality Improvement Toolbox: Provides resources for quality improvement projects.

Patient Centered Medical Home (PCMH) Resource Center

PDSA: Plan, Do, Study, Act by Adam Strom & Andrea Kaminski.

Safety Net Medical Home Initiative: Idaho's Quality Improvement Network (QIN) resource and tools page for Idaho healthcare providers.

Hypertension Treatment Protocol Development

Team-based Care

Team-based care has been identified by The Community Guide as an evidenced-based practice to improve blood pressure control for patient populations.  Below are resources about team-based care.

The Community Guide: Provides information on the evidence-base for team-based care.
Safety Net Medical Home Initiative: Provides resources for implementing team-based care.

Agency for Healthcare Research and Quality:
Practice Facilitation Handbook: Module 19. Implementing Care Teams

National Diabetes Education Program:Provides diabetes related resources.

Adult Hypertension Clinical Practice Guidelines: Beginning on approximately page 25 of the following electronic document begins a description of a team-based hypertension control improvement project. 
Evidence-Based Health Coaching and Chronic Care Video Library: Provides a library of motivational interviewing videos for healthcare providers. They address a wide variety of topics for healthcare teams. 

Why Weight? A Guide to Discussing Obesity & Health with Your Patients

Evidence-based weight management resources:

TOPS- Take Pounds Off Sensible Weight Watchers

Clinical Decision-Support System Resources

Million Hearts Treatment Protocols for Hypertension

National Diabetes Education Program: Provides diabetes related resources.

How could a Community Health Worker benefit you?

CHWs are not clinicians or healthcare providers. The services they provide do not replace the level of care that physicians, nurses and physician assistants provide to patients. As an integrated member of your care team, they can assist with the daily challenges you face like time, follow-up and patient education.

CHWs can assist with:

• Case management and care coordination • Outreach and Community Education
• Health promotion and health coaching • Community and cultural competence
• Home-based support • Basic initial health screenings

Watch Idaho Healthcare professionals and CHWs share their successes and experiences serving Idaho's rural and urban communities. 

Diabetes Prevention Program

Are your patients at risk for type 2 diabetes?  Test them today for prediabetes and recommend a Diabetes Prevention Program (DPP) for those at risk. 

CDC’s National Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for preventing type 2 diabetes. The Diabetes Prevention Program research study showed that lifestyle changes reduced the risk of developing type 2 diabetes by 58% in people with prediabetes.  The DPP is a year-long program with 16 weekly sessions and 8 monthly follow-up sessions with trained lifestyle coaches who empower participants to take charge of their health. 

Which Patients Are Eligible for DPP? 
To participate, patients must: 
• Be at least 18 years old; 
• Be overweight BMI greater than or equal to 24; greater than or equal to 22 if Asian.
• Have established risk factors for developing type 2 diabetes; or 
• Have been diagnosed with prediabetes within the past year or previously diagnosed with gestational diabetes. 

Recommending Patients Is Easy! 
Find a DPP in your area and contact a lifestyle coach to obtain a recommendation form and refer those patients who are at risk for type 2 diabetes.

Prevent Diabetes STAT (Screen/Test/Act Today): See how a practice like yours is screening, testing and acting today to prevent diabetes. 

Diabetes Self-Management Education/Training (DSME/T)

Almost one out of six
of your adult patients has or is at risk of developing diabetes. Diabetes control achieved through diabetes self-management education can improve health outcomes. Refer your patients to an ADA recognized or AADE-accredited Diabetes Self-Management Education (DSME) Program. With a referral, classes are covered by Medicare, Medicaid and most insurance plans.

Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) benefits are alarmingly underutilized by Medicare beneficiaries.  

Data from the Medicare Quality Improvement Organizations (QIOs) reveals the root causes of this under utilization are limited awareness/confusion of the benefits and how to order the benefits for a patient.

The response: AADE and ADA joined forces to develop the Diabetes Services Order Form, which is designed to be an easy and convenient way for a physician or a qualified non-physician practitioner to refer their Medicare patients with diabetes to a diabetes educator for DSMT and a registered dietitian for MNT.

The standardized referral form can be used by any facility or healthcare professional and includes the key referral information required to meet Medicare regulatory requirements for MNT and/or DSMT referrals, but the form itself is not required by Medicare.

Physician educational resource:

  • AADE and ADA have also developed a backgrounder and education fact sheet that includes a summary of the Medicare MNT benefit requirements and DSMT requirements, as well as examples of how MNT and the DSMT services can be coordinated for qualifying Medicare beneficiaries.

  • New ICD-10 Codes for Diabetes Self-Management Training: October 1, 2015 marked the switch from ICD-9 codes to ICD-10 codes. The new set of codes is greatly expanded from the previous version, allowing for more specificity in diagnoses.  Learn more and see the codes now. For additional information about the codes, check out these resources.

Order Free Health Tools

The right tools can make all the difference, visit Health Tools ( to order FREE materials to help others learn about diabetes, heart disease, stroke, blood pressure and developing healthy habits. You'll find brochures, cards, posters and educational items for ordering.

Resources for Teachers, Coaches and Other School Staff

Helping the Student with Diabetes Succeed: A Guide for School Personnel:

This comprehensive resource guide helps students with diabetes, their health care team, school staff, and parents work together to provide optimal diabetes management in the school setting. View or download School Guide promotional tools.

Coaching Youth to Success: Healthy Players Make a Winning Team!

Provided as an interactive DVD, the coach’s handbook covers common health and safety issues in youth.