Category A: Diabetes Management and Type 2 Diabetes Prevention Strategies
A.1. Implement systems to facilitate bi-directional e-referrals between health care systems and the National DPP lifestyle change programs.
A.2. Support organizations in increasing enrollment in existing National DPP lifestyle change programs or establishing and sustaining new National DPP lifestyle change programs in underserved areas.
A.3. Implemented tailored communication/messaging to reach underserved populations at greatest risk for type 2 diabetes to increase awareness of prediabetes and National DPP lifestyle change programs.
A.4. Support advanced training for lifestyle coaches working at the National DPP lifestyle change programs to strengthen the skills needed to engage and retain patients.
A.5. Explore and test innovative ways to eliminate barriers to participation and retention in National DPP lifestyle change programs and/or American Diabetes Association-recognized (ADA-recognized) and American Association of Diabetes Educator-accredited (AADE-accredited) diabetes self-management education and support (DSMES) programs for diabetes-management among high burden populations.
A.6. Work with health care systems to establish or expand use of telehealth technology to increase access to National DPP lifestyle change programs and ADA-recognized and AADE-accredited DSMES programs for diabetes management.
A.7. Increase adoption and use of clinical systems and care practices to improve health outcomes for persons with diabetes.
A.8. Increase use of clinical decisions support within the electronic health record (EHR) to promote early detection of chronic kidney disease (CKD) in people with diabetes.
Category B: Cardiovascular Disease Prevention and Management Strategies
B.1. Increase identification of patients with undiagnosed hypertension using electronic health records (EHRs) and Health Information Technology (HIT).
B.2. Explore and test innovative ways to promote the adoption of evidence-based quality measurement at the provider level.
B.3. Explore and test innovative ways to engage non-physician team members (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol management (i.e., diagnosis and medication management) in clinical settings.
B.4. Promote the adoption of Medication Therapy Management (MTM) between community pharmacists and physicians for the purpose of managing high blood pressure, high blood cholesterol, and lifestyle modification.
B.5. Facilitate engagement of community health workers (CHWs) in hypertension and cholesterol management in clinical and community settings.
B.6. Implement systems to facilitate bi-directional e-referrals between community programs/resources and health care systems (e.g., using EHRs, 800 numbers, 211 referral systems, etc.).
B.7. Explore and test innovative ways to expand use of telehealth including mobile health technology.
B.8. Explore and test innovative ways to enhance referral, participation, and adherence in cardiac rehabilitation programs in traditional and community settings, including home-based settings.