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Change Packages and Interventions
Change Packages and Interventions
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Diabetes
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Diabetes Action Plan
Give this tool to patients so they can create a diabetes action plan. Patients will be able to make plans in key areas, including exercise, diet and foot care.
Adobe PDF
Date Added:
06/01/2023
Date Last Modified:
Jun 1 2023 1:50PM
HANDOUT: Diabetes Action Plan
TRANSCRIPT: Diabetes Action Plan
America's Health Rankings 2023 Senior Report
The report provides a portrait of the health and well-being of older adults across the United States. The report covers social and economic factors, physical environment, clinical care, behaviors and health outcomes. It includes state-by-state summaries and county-level maps for risk of social isolation by state.
Adobe PDF
Date Added:
05/26/2023
Date Last Modified:
Jul 28 2023 1:06PM
HANDOUT: America's Health Rankings 2023 Senior Report
TRANSCRIPT: America's Health Rankings 2023 Senior Report
Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System
This study shows that rural patients have worse diabetic quality metrics than their urban counterparts, even when controlling for common contributing factors within the same integrated health system.
Web link
Date Added:
05/23/2023
Date Last Modified:
May 26 2023 12:21PM
HANDOUT: Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System
TRANSCRIPT: Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System
Food Insecurity is a Leading Health-Related Social Need Among Patients With Diabetes
This article discusses how the physical and economic burdens of living with type 2 diabetes may make it harder for Medicare beneficiaries to afford, access and prepare health-promoting food.
Web link
Date Added:
05/15/2023
Date Last Modified:
May 15 2023 9:09AM
HANDOUT: Food Insecurity is a Leading Health-Related Social Need Among Patients With Diabetes
TRANSCRIPT: Food Insecurity is a Leading Health-Related Social Need Among Patients With Diabetes
Food Security: Key Dimensions of the Social Determinant of Health
This article examines how food access and security affects health and well-being. It states that many illnesses, such as heart disease and diabetes, may be diet-related. However, through community health partnerships, health care organizations are trying to connect patients in need with nutritious food.
Web link
Date Added:
04/07/2023
Date Last Modified:
Apr 7 2023 12:18PM
HANDOUT: Food Security: Key Dimensions of the Social Determinant of Health
TRANSCRIPT: Food Security: Key Dimensions of the Social Determinant of Health
Measuring And Addressing Nutrition Security To Achieve Health And Health Equity
This article explores food insecurity and the impact nutrition-related diseases have on health inequity and health care costs in the US and globally. The article also offers potential interventions to address nutrition security in different populations.
Web link
Date Added:
04/07/2023
Date Last Modified:
Apr 7 2023 12:48PM
HANDOUT: Measuring And Addressing Nutrition Security To Achieve Health And Health Equity
TRANSCRIPT: Measuring And Addressing Nutrition Security To Achieve Health And Health Equity
DDRC Patient Prepardedness Plan
Emergency preparedness for people with diabetes includes building a “diabetes kit.” The Diabetes Disaster Response Coalition (DDRC) has created guidelines for building such a kit. Included is a checklist of important information to keep in the kit, as well as a list of extra supplies that people with diabetes should always have on hand.
Adobe PDF
Date Added:
03/13/2023
Date Last Modified:
Mar 13 2023 8:50AM
HANDOUT: DDRC Patient Prepardedness Plan
TRANSCRIPT: DDRC Patient Prepardedness Plan
Type 2 Diabetes Management Barriers in People of Color
This article focuses on some of the barriers that minorities face when trying to manage their Type 2 diabetes. These barriers include lack of diabetes education, as well as limited access to fresh fruits and vegetables and transportation to health care services.
Web link
Date Added:
03/09/2023
Date Last Modified:
Mar 9 2023 12:33PM
HANDOUT: Type 2 Diabetes Management Barriers in People of Color
TRANSCRIPT: Type 2 Diabetes Management Barriers in People of Color
All About your A1C
Download this fact sheet from the TMF Quality Innovation Network to learn more about the A1C blood test and the results the test provides.
Adobe PDF
Date Added:
02/24/2023
Date Last Modified:
Mar 6 2023 2:19PM
HANDOUT: All About your A1C
TRANSCRIPT: All About your A1C
Diabetes Study to Assess Approaches to Social Determinants
Researchers at the University of Alabama at Birmingham and the University of Mississippi Medical Center are studying sustainable and effective Type 2 diabetes management interventions in adults who have Type 2 diabetes and sub-optimal social determinants of health. The study will enroll patients in Alabama and Mississippi to evaluate variables such as health coaching, food delivery and remote patient-monitoring to see which will help patients manage diabetes.
Web link
Date Added:
02/20/2023
Date Last Modified:
Feb 20 2023 7:56AM
HANDOUT: Diabetes Study to Assess Approaches to Social Determinants
TRANSCRIPT: Diabetes Study to Assess Approaches to Social Determinants
Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes
Researchers found that engaging family caregivers a health coaching program can lead to better patient activation and chronic disease management for people with diabetes, according to a new randomized trial published in JAMA Network Open.
Web link
Date Added:
02/20/2023
Date Last Modified:
Feb 20 2023 7:38AM
HANDOUT: Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes
TRANSCRIPT: Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intervention List
Download this two-page handout the TMF Quality Innovation Network created to help health care providers and practitioners find and implement quality improvement interventions to help patients take an active role in managing their diabetes and prediabetes.
Adobe PDF
Date Added:
02/15/2023
Date Last Modified:
Feb 15 2023 10:26AM
HANDOUT: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intervention List
TRANSCRIPT: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intervention List
The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic
Physical therapists commonly prescribe physical activity for the treatment of diabetes and diabetes-related complications that modify traditional musculoskeletal exercise prescription. Physical therapists must advocate for regular physical activity as a key component of the treatment of chronic diseases in all patient interactions.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 10:01AM
HANDOUT: The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic
TRANSCRIPT: The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic
Increasing Access to Diabetes Education
The Centers for Disease Control and Prevention (CDC) is working to identify and remove barriers to access and participation in diabetes self-management education and support (DSMES) services. Although the benefits of DSMES are well known, fewer than 5% of Medicare beneficiaries use these services in their first year of diagnosis. This CDC resource focuses on reaching populations and communities with limited access that have higher rates of diabetes and higher risk of complications.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:49AM
HANDOUT: Increasing Access to Diabetes Education
TRANSCRIPT: Increasing Access to Diabetes Education
Diabetes Prevention Recognition Program Registry
The National Registry of Recognized Diabetes Prevention Programs lists contact information for all organizations, recognized by the Centers for Disease Control and Prevention, that deliver evidence-based type 2 diabetes prevention programs in the United States. All of these programs use a CDC-approved curriculum that meets the duration, intensity and reporting requirements described in the DPRP Standards.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:50AM
HANDOUT: Diabetes Prevention Recognition Program Registry
TRANSCRIPT: Diabetes Prevention Recognition Program Registry
Anaerobic Exercise and Diabetes
Anaerobic exercise is the act of moving, and it is particularly beneficial to heart health and lowering blood glucose levels. For people who need an alternative to the walking plan, anaerobic exercise provides comparable benefits. This resource, from the American Diabetes Association, acts as a guide to incorporate weight training and different levels of activity for strengthening.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:52AM
HANDOUT: Anaerobic Exercise and Diabetes
TRANSCRIPT: Anaerobic Exercise and Diabetes
Breaking Sitting Streaks
The "Standards of Medical Care in Diabetes" recommends that everyone break up bouts of sitting with brief activity every 30 minutes. Such mini exercise bursts may be particularly beneficial for people with type 2 diabetes. This resource, from the American Diabetes Association, includes a helpful guide that gives innovative ideas on how to move while netting stronger muscles and a higher daily calorie burn.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:54AM
HANDOUT: Breaking Sitting Streaks
TRANSCRIPT: Breaking Sitting Streaks
Exercise and Type 1
Regular physical activity is important for overall health and wellness. For those with type 1 diabetes, it’s very important to balance insulin doses with food eaten and activity. Planning ahead and knowing how blood sugar and the body respond to exercise can help keep blood sugar levels from getting too low or too high.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:55AM
HANDOUT: Exercise and Type 1
TRANSCRIPT: Exercise and Type 1
Managing Diabetes
The National Institute of Diabetes and Digestive and Kidney Diseases provides a comprehensive list on managing diabetes, meal plans, physical activity, medications, and blood glucose levels. This resource introduces methods to cope with diabetes in healthy ways and collaborate with the healthcare team.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:57AM
HANDOUT: Managing Diabetes
TRANSCRIPT: Managing Diabetes
Continuous Glucose Monitoring
The National Institute of Diabetes and Digestive and Kidney Diseases provides a comprehensive This guide, from the National Institute of Diabetes and Digestive and Kidney Diseases, answers all the questions a patient might have about continuous glucose monitoring (CGM). This resource includes illustrations for further explanation and guidance for successful CGM use.
Web link
Date Added:
01/27/2023
Date Last Modified:
Jan 27 2023 9:59AM
HANDOUT: Continuous Glucose Monitoring
TRANSCRIPT: Continuous Glucose Monitoring
Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care
This study, published in the Annals of Family Medicine in September 2022, examines how community health workers - who are part of a health care team - influence the health outcomes of patients with type 2 diabetes.
Web link
Date Added:
11/28/2022
Date Last Modified:
Nov 28 2022 5:42PM
HANDOUT: Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care
TRANSCRIPT: Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care
Living With Diabetes
This website offers education, support and resources to improve the quality of life for people with diabetes.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:40AM
HANDOUT: Living With Diabetes
TRANSCRIPT: Living With Diabetes
Comprehensive Type 2 Diabetes Management Algorithm (2020) – Executive Summary
Since originally drafted in 2013, the algorithm for the comprehensive management of persons with type 2 diabetes has been updated with new therapies, management approaches and clinical data. The current algorithm includes up-to-date sections on lifestyle therapy and all classes of obesity, antihyperglycemic, lipid-lowering and antihypertensive medications approved by the U.S. Food and Drug Administration.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:27AM
HANDOUT: Comprehensive Type 2 Diabetes Management Algorithm (2020) – Executive Summary
TRANSCRIPT: Comprehensive Type 2 Diabetes Management Algorithm (2020) – Executive Summary
Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement
In this update to its 2015 recommendation, the U.S. Preventive Services Task Force recommends that adults, ages 35-to-70, get screened for prediabetes and type 2 diabetes if they are overweight or obese. USPSTF also recommends that clinicians offer or refer patients with prediabetes to effective type 2 diabetes prevention programs.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:31AM
HANDOUT: Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement
TRANSCRIPT: Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement
Conduct Practice-Based Screening
One-fourth of Americans who have Type 2 diabetes — and nearly twice that proportion among Asian and Hispanic Americans — are unaware they have it. The American Diabetes Association offers recommendations for testing for diabetes or prediabetes in asymptomatic adults.
Adobe PDF
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:52AM
HANDOUT: Conduct Practice-Based Screening
TRANSCRIPT: Conduct Practice-Based Screening
Tools for the team: Diabetes prevention toolkit
This website lists resources and templates to help providers implement diabetes prevention strategies for patients with diabets. The site also includes educational materials for health care professionals and patients on a variety of diabetes prevention topics.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:33AM
HANDOUT: Tools for the team: Diabetes prevention toolkit
TRANSCRIPT: Tools for the team: Diabetes prevention toolkit
National Diabetes Prevention Program Coverage Toolkit
This online toolkit was developed to provide information about the National Diabetes Prevention Program (National DPP) lifestyle change program. National DPP is a year-long, evidence-based intervention program developed by the Centers for Disease Control and Prevention. There is a video you can watch that provides an overview of the toolkit and suggests how participants can best use the resources.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:36AM
HANDOUT: National Diabetes Prevention Program Coverage Toolkit
TRANSCRIPT: National Diabetes Prevention Program Coverage Toolkit
The Impact of Point-of-Care Hemoglobin A1c Testing on Population Health-Based Onsite Testing Adherence: A Primary-Care Quality Improvement Study
This article discusses the results of a study among adult patients with diabetes due for HbA1c testing across three primary care practices. One conclusion: Practices with HbA1c point-of-care testing improves testing adherence at office visits, thereby resulting in better diabetes management for patients with worsening disease.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:42AM
HANDOUT: The Impact of Point-of-Care Hemoglobin A1c Testing on Population Health-Based Onsite Testing Adherence: A Primary-Care Quality Improvement Study
TRANSCRIPT: The Impact of Point-of-Care Hemoglobin A1c Testing on Population Health-Based Onsite Testing Adherence: A Primary-Care Quality Improvement Study
Diabetes Care Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes
This consensus report addresses how to best manage glycemia in adults with type 2 diabetes. New recommendations emerging from a literature review is an addiitonal focus on lifestyle management and diabetes self-management education and support.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:45AM
HANDOUT: Diabetes Care Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes
TRANSCRIPT: Diabetes Care Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes
Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes
According to this study, comprehensive telehealth interventions can successfully address and help reverse poor control of type 2 diabetes, even in rural areas.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:48AM
HANDOUT: Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes
TRANSCRIPT: Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes
Diabetes and Health Centers
Health centers serve one in 11 people across the country, including the one in seven that has diabetes. The Health Center Program launched the Diabetes Quality Improvement Initiative to help patients control their diabetes.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:50AM
HANDOUT: Diabetes and Health Centers
TRANSCRIPT: Diabetes and Health Centers
KnowDiabetesbyHeart™
This website features the latest cardiovascular and diabetes science, patient educational and clinical care tools and quality improvement programs. The American Heart Association and the American Diabetes Association created the website together, with the goal to reduce cardiovascular death, heart attack, stroke and heart failure in people living with type 2 diabetes.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 9:04AM
HANDOUT: KnowDiabetesbyHeart™
TRANSCRIPT: KnowDiabetesbyHeart™
Guiding Principles for the Care of People With or at Risk for Diabetes
These updated Guiding Principles now include new approaches to caring for patients with diabetes, including helping them develop the skills to self-manage their disease. A PDF version of the Principles are available for download at this website.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:54AM
HANDOUT: Guiding Principles for the Care of People With or at Risk for Diabetes
TRANSCRIPT: Guiding Principles for the Care of People With or at Risk for Diabetes
Prevent Type 2 Diabetes, Prediabetes identification
This tool gives primary care providers step-by-step instructions for identifying patients who may have prediabetes. It also gives providers next steps for patients diagnosed with prediabetes.
Adobe PDF
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:58AM
HANDOUT: Prevent Type 2 Diabetes, Prediabetes identification
TRANSCRIPT: Prevent Type 2 Diabetes, Prediabetes identification
Guiding Principles for the Care of People With or at Risk for Diabetes, PDF
Over the years, multiple organizations have independently developed and updated evidence-based guidelines for the care of people with or at risk for diabetes. These updated Guiding Principles identify and synthesize myriad guidelines primary care providers and health care teams can use when delivering quality care to adults with or at risk for diabetes.
Adobe PDF
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 8:56AM
HANDOUT: Guiding Principles for the Care of People With or at Risk for Diabetes, PDF
TRANSCRIPT: Guiding Principles for the Care of People With or at Risk for Diabetes, PDF
Prevent Type 2 Diabetes, Prediabetes identification, FAQs
This resource is a compilation of frequently asked questions about prediabetes.
Adobe PDF
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 9:00AM
HANDOUT: Prevent Type 2 Diabetes, Prediabetes identification, FAQs
TRANSCRIPT: Prevent Type 2 Diabetes, Prediabetes identification, FAQs
Understanding A1C: A1C does it all
This patient resource explains the information that A1c blood test results provides. It averages blood sugar levels over two-to-three months. The higher the levels, the greater a patient's risk of developing diabetes complications.
Web link
Date Added:
05/17/2022
Date Last Modified:
May 17 2022 9:02AM
HANDOUT: Understanding A1C: A1C does it all
TRANSCRIPT: Understanding A1C: A1C does it all
Optimize your EHR to prevent type 2 diabetes
The American Medical Association offers suggestions and guidance on how providers can use electronic health records (EHRs) and technology to improve care for patients with prediabetes.
Adobe PDF
Date Added:
05/05/2022
Date Last Modified:
May 5 2022 12:33PM
HANDOUT: Optimize your EHR to prevent type 2 diabetes
TRANSCRIPT: Optimize your EHR to prevent type 2 diabetes
Guide to Clinical Care and Patients with Diabetes and Established Cardiovascular Risk
In the Know Diabetes by Heart Pocket Guide, the American Heart Association and the ADA summarize key clinical recommendations for cardio-metabolic health management for people with type 2 diabetes.
Adobe PDF
Date Added:
05/05/2022
Date Last Modified:
May 5 2022 12:36PM
HANDOUT: Guide to Clinical Care and Patients with Diabetes and Established Cardiovascular Risk
TRANSCRIPT: Guide to Clinical Care and Patients with Diabetes and Established Cardiovascular Risk
ADCES7 Self-Care Behaviors™ REDUCING RISKS
Providers can give this handout to patients diagnosed with prediabetes or type 2 diabetes. This patient education tool from the Association of Diabetes Care & Education Specialists (ADCES7) is intended to help patients take an active role in keeping their hearts, kidneys and eyes healthy while they manage their diabetes.
Adobe PDF
Date Added:
05/05/2022
Date Last Modified:
May 5 2022 12:44PM
HANDOUT: ADCES7 Self-Care Behaviors™ REDUCING RISKS
TRANSCRIPT: ADCES7 Self-Care Behaviors™ REDUCING RISKS
Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care with a Quality Initiative
Read how Tulane Medical Group used the Diabetes INSIDE (Inspiring System Improvement with Data-Driven Excellence) program to conduct a multiyear review of outpatient EHRs to improve outcomes of patients with adult type 2 diabetes. The goal: to decrease hemoglobin A1C (HbA1c) under-testing, reduce the number of patients with poor glycemic control and lower HbA1c levels.
Web link
Date Added:
05/05/2022
Date Last Modified:
May 5 2022 12:38PM
HANDOUT: Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care with a Quality Initiative
TRANSCRIPT: Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care with a Quality Initiative
Information for Health Care Professionals
The National Diabetes Prevention Program—or National DPP—was created in 2010 to address the increasing number of people diagnosed with prediabetes and type 2 diabetes in the United States. Health care professionals can refer their at-risk patients to a CDC-recognized lifestyle change program that focuses on changing certain habits and behaviors that contribute to poor health.
Web link
Date Added:
05/05/2022
Date Last Modified:
May 5 2022 12:41PM
HANDOUT: Information for Health Care Professionals
TRANSCRIPT: Information for Health Care Professionals
Improving Chronic Disease Self-Management Diabetes Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address diabetes prevention, self-management and care.
Adobe PDF
Date Added:
09/28/2020
Date Last Modified:
Oct 1 2020 1:29PM
HANDOUT: Improving Chronic Disease Self-Management Diabetes Change Package
TRANSCRIPT: Improving Chronic Disease Self-Management Diabetes Change Package
Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Diabetes, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para abordar la prevención, el automanejo y la atención de la diabetes.
Adobe PDF
Date Added:
11/09/2020
Date Last Modified:
Nov 11 2020 5:46PM
HANDOUT: Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Diabetes, para Puerto Rico
TRANSCRIPT: Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Diabetes, para Puerto Rico