Table 2—

Case management interventions

Blood glucose management• Self-monitoring of blood glucose (SMBG): individual education and ongoing assessment to reach individually defined targets.
• Testing frequency: as needed to meet treatment goals, generally at least two times per day.
• Glucose records: maintained by participant; results reviewed each visit and compared with meter memory.
• Data review: SMBG trends/patterns identified; collaboration with primary care provider to modify treatment.
• Treatment: strategies individualized to meet goals.
Nutrition education and management• Weight: measured at every visit.
• Treatment: individualized meal plans to meet nutrition and weight-management goals.
• Routine assessment: content, quantity, and timing of food intake; adjustments as needed.
Exercise• Assessment of physical activity: at least quarterly.
• Exercise stress testing: when advisable/available.
• Exercise plan: incorporation of current activity preference and level; increased as tolerated.
Foot care• Visual inspection/examination at least quarterly.
• Education: daily self-inspection and preventive care.
• Referrals for specialty care: as needed.
Monitoring of participant progress and retention• Record sheets: developed to promote ongoing participant assessment and provider communication (monitor appointments, physical measurements, laboratory values, SMBG results, active problems, treatment, etc.).
• Retention strategies: 1) interim visit telephone contact; 2) appointment reminders/tracking/rescheduling; 3) group education/social activities; 4) holiday/special greeting cards.
• Written record of participant interactions: shared with primary care providers to ensure continuity and quality of care.
• Community support: family/significant others encouraged to attend appointments and events.
• Communication: bilingual study staff and native language print materials used when possible.
• Interpretation services: telephone company interpretation service; bilingual clinic staff assistance.
• Staff reassignment: as needed to optimize participant interactions, care, and retention.
• Ongoing self-management assessment: provide or refer for diabetes education, nutrition, and/or exercise guidance, psychosocial support, or community assistance resources.
Retinopathy prevention/ treatment• Retinal examinations and/or retinal photographs: at least yearly.
• Ophthalmologic follow-up: direct referral to an ophthalmologist; results obtained and forwarded to primary care provider.
Nephropathy prevention/treatment• Microalbumin: assessed at least yearly.
• Results: abnormal results flagged, primary care provider notified.
• Prevention/treatment: optimize blood glucose and blood pressure control; initiation of ACE inhibitors.
Hypertension management• Blood pressure measurements: at every visit.
• Target: ≤135/85 mmHg; more frequent monitoring and treatment if target exceeded.
• Treatment: diet and exercise modifications, weight management, pharmacological therapy.
Dyslipidemia management• Fasting assessment: at least yearly.
• Target: total cholesterol <200 mg/dl, LDL <130 mg/dl, triglycerides <150 mg/dl.
• Treatment: dietary and exercise modifications; pharmacological therapy as indicated.
Cardiovascular disease prevention/treatment• Risk factor assessment: at least yearly.
• Smoking cessation: encouraged; referral to community programs.
• Weight management: encouraged; referral to community-based dietary counseling or programs.
• Aspirin and hormonal replacement therapy: initiated when appropriate.
Disenrollment from the study• Criteria for early termination:
 • withdrawal of consent;
 • inability to keep appointments or respond to oral/written contact for 6 consecutive months;
 • loss of Medi-Cal beneficiary status;
 • geographic relocation;
 • death.