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. |