[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-262386-105":53,"doc-detail-262386-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","diabetes-case-manager-promising-practice-overview-actions-taken-aim-measures-results-to-date","Diabetes Case Manager - Promising Practice Overview - Actions Taken, Aim, Measures, Results to Date","","Diabetes case management is delivered by a Registered Nurse at Alexander Valley Healthcare to help patients with diabetes, prediabetes, and obesity build sustainable lifestyle changes. The program provides free, bilingual appointments (with limited billing), supports the nurse’s diabetes educator certification, and reviews medications, BMI, glucose logs, vitals, cholesterol, food recall, and laboratory status across visits. Targeting HbA1c control (≤9%), outcomes show improved A1c rates from April 2017 through 2018, supported by culturally appropriate nutrition materials, referrals, and warm handoffs.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":11,"@type":70,"position":76},"https://docshare.wps.com/template/presentations/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/diabetes-case-manager-promising-practice-overview-actions-taken-aim-measures-results-to-date/262386/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/diabetes-case-manager-promising-practice-overview-actions-taken-aim-measures-results-to-date/262386.png","ImageObject",442,249,{"name":88,"@type":89},"Stanford","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-01","2026-09-14",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the primary role of the RN case manager in this promising practice?","Question",{"text":109,"@type":110},"The RN case manager meets one-on-one with patients struggling to manage diabetes, reviews health and lab data, and provides education to support medication adherence and lifestyle goals.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What measures are used to evaluate diabetes outcomes?",{"text":114,"@type":110},"The program tracks UDS Diabetes: Hemoglobin A1c Control, specifically the percentage of adults 18–75 with HbA1c less than or equal to 9.0 percent during the measurement period.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the program support patients’ access to healthy food?",{"text":118,"@type":110},"The case manager refers patients to food pantries, farmer’s markets, and WIC offices, and partners with CERES Community Project for nutrition assistance referrals for patients with Congestive Health Failure.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},262386,1791302574,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":8,"category_name":11,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76,"preview_page_count":4},2336477552062,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","August 1st, 2019  \nDiabetes Case Manager  \nRedwood Community Health Coalition Promising Practice  \nThis project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H2QCS30258, Health Center Controlled Networks, for $1,500,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be  \ninferred by HRSA, HHS or the U.S. Government  \nPROMISING PRACTICE OVERVIEW  \nACTIONS TAKEN  \nAlexander Valley Healthcare (AVH) utilizes the knowledge and skillset of one of their Registered Nurses (RN) to act as a Case Manager (CM) to help patients with diabetes manage their disease and work on lifestyle goals. This CM began working 32 hours a week in this role in August 2017. She also sees patients with prediabetes and obesity (adults and children) .  \nAppointments with the CM are free and bilingual. At this point, AVH cannot bill for these visits. The CM is currently undergoing diabetes educator certification through the National Diabetes Educator Association. Keeping up with recommended medications is challenging. There are other CMs at AVH that work in similar ways with patients and collaborate with one another.  \nAIM  \nTo lower Alc rates and accomplish lifestyle changes (including healthy eating) among patients with diabetes through working with an RN case manager.  \nMEASURES  \nUDS Diabetes: Hemoglobin A1c Control (\u003C=9%)  \nPercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c (HbA1c) less than or equal to 9.0 percent during the measurement period.  \nRESULTS TO DATE  \nAVH’s A1c rate improved from 57% in April 2017, to 62% when the CM was working 1 day a week in this role. The rate continued to increase to 69% in 2018 after the CM increased to 32 hours a week, and is currently at 74% . While the CM started working in her current role at AVH in April 2017, she’d worked as a nurse DM educator for 5 years. She understands the importance of having culturally appropriate nutrition information and created her own materials to suit the culture and education level of her patients.  \nPROMISING PRACTICE OVERVIEW  \n􀂃 Developed role for CM to meet one-on-one with patients (pts) struggling to manage diabetes. CM can create pt appts on their schedule and works until 7 pm on Monday to see more pts.  \n􀂃 Reviews pt: Medications (any problems with access or cost), BMI, blood sugar log (from at home glucometer), blood pressure, cholesterol, completes 24 hour food recall, and ensures all labs are up to date. Continues to review this data through all appts.  \n􀂃 Educates: 1. Why/when to check blood sugar and 2. Healthy eating based on ADA guidelines. CM sets dietary goals with pt.  \n􀂃 Refer pts to CM directly from providers, including warm hand offs.  \n􀂃 Aim for pts to see CM at least monthly.  \n􀂃 Refers pts to food pantries, farmer’s markets, and WIC offices to connect pts with affordable healthy food.  \n􀂃 Partners with CERES Community Project to refer pts with Congestive Health Failure for nutrition assistance.  \nWORKFLOW  \n1. CM conducts  \nmonthly outreach to pts with poorly managed diabetes based on Relevant list. Providers also ID pts through Relevant and refer.  \n3. Pt has 2nd appt with CM 2 weeks later. CM reviews diet again and sends telephone encounter to PCP about any medications that need to be adjusted.  \nReferral & 1st appt  \n2nd appt  \nFollow-up appts  \n4. Pt sees CM  \nuntil A1c is at goal (around 6-8 appts) . Afterward, pt can continue to see CM if they choose.  \nA1c Rate  \n100% ~~ ~~  \n80%  CMworstartsking 1 CMworstartsking 32   \nday/week hrs/week   \n60%   \n40% ~~ ~~  \n20% ~~ ~~  \n0% ~~   ~~  \nApr-17 Jul-17 Oct-17 Jan-18 Apr-18 Jul-18 Oct-18 Jan-19 Apr-19  \nLESSONS LEARNED  \nAVH recognized that having a CM work with and educate patients with diabetes was beneficial to patients. Although they can’t bill for these visits, AV","cbCaipe8ytGS8ElM","https://ap.wps.com/l/cbCaipe8ytGS8ElM","pdf",4855790,7,"English","# Promising Practice Overview\n## Actions Taken\n## Aim\n## Measures\n## Results to Date\n## Workflow\n## Lessons Learned\n## Diabetes Nutrition Education Tools","[{\"question\":\"What is the primary role of the RN case manager in this promising practice?\",\"answer\":\"The RN case manager meets one-on-one with patients struggling to manage diabetes, reviews health and lab data, and provides education to support medication adherence and lifestyle goals.\"},{\"question\":\"What measures are used to evaluate diabetes outcomes?\",\"answer\":\"The program tracks UDS Diabetes: Hemoglobin A1c Control, specifically the percentage of adults 18–75 with HbA1c less than or equal to 9.0 percent during the measurement period.\"},{\"question\":\"How does the program support patients’ access to healthy food?\",\"answer\":\"The case manager refers patients to food pantries, farmer’s markets, and WIC offices, and partners with CERES Community Project for nutrition assistance referrals for patients with Congestive Health Failure.\"}]","Diabetes Case Manager - Promising Practice Overview - Actions Taken, Aim, Measures, Results to Date | PDF",1789361701]