Community Programs Linked to Clinical Services

Resources for Diabetes and Hypertension



Accountable Care Organization (ACO)
A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursement to quality metrics and reductions in the total cost of care for an assigned population of patients

Affordable Care Act (ACA)
A federal statute signed into law in March 2010 as a part of the healthcare reform agenda of the Obama administration

America’s Health Insurance Plans (AHIP)
America’s Health Insurance Plans is the national association representing nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans.

American Academy of Family Physicians (AAFP)
Representing more than 110,600 family physicians, residents, and medical student members, the AAFP is committed to helping family physicians improve the health of Americans by advancing the specialty of family medicine. Their focus is to help family physicians spend more time doing what they do best: providing quality and cost-effective patient care.

American Association of Diabetes Educators (AADE)
The AADE is a multi-disciplinary professional membership organization dedicated to improving diabetes care through education. With more than 13,000 professional members including nurses, dietitians, pharmacists, and others, AADE has a vast network of practitioners involved in the daily treatment of diabetes patients. The AADE’s mission is to empower healthcare professionals with the knowledge and skills to deliver exceptional diabetes education, management and support.

American Diabetes Association (ADA)
ADA funds research to prevent, cure and manage diabetes, delivers services to hundreds of communities, provides objective and credible information, and conducts advocacy work at the local, state, and national level.

Association of State and Territorial Health Officials (ASTHO)
ASTHO is the national nonprofit organization representing public health agencies in the United States, the U.S. Territories, and the District of Columbia, and over 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, formulate and influence sound public health policy and ensure excellence in state-based public health practice. ASTHO’s primary function is to track, evaluate, and advise members on the impact and formation of public or private health policy and to provide guidance and technical assistance on improving the nation’s health.

Case Management
Also referred to as ‘care coordination’ or ‘care management’, case management is the process of helping an individual or family explore options and services based on a review of a person’s or family’s needs. A case manager plans, implements, coordinates, monitors and/or evaluates the provision of all the selected services.

Centers for Medicare and Medicaid Services (CMS)
A division of the Department of Health and Human Services (HHS) that administers the Medicare program and some aspects of state Medicaid programs

CDC Chronic Disease Prevention and Health Promotion Domains
  • Domain 1: Epidemiology and surveillance is a core public health function in which all state departments of health are engaged. The investment in this activity supports states to build and maintain expertise to collect data and information and to develop and deploy effective interventions, identify gaps in program delivery, and monitor and evaluate progress in achieving program goals. Data and information from these efforts can and should be used routinely to inform decision makers and the public about the effectiveness of preventive interventions (including program effectiveness and public health impact) and the burden and unmet need of chronic diseases and associated risk factors.
  • Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors facilitate improvements in social and physical environments to make healthy behaviors easier and more convenient for Americans. The investment in this activity supports state-level and/or statewide programmatic efforts and targeted efforts in schools, early care and education (ECE), worksites, and communities.
  • Domain 3: Health system interventions to improve the quality, effective delivery and use of clinical and other preventive services in order to prevent disease, detect disease early, and reduce or eliminate risk factors and mitigate or manage complications. Health systems interventions improve the clinical environment to more effectively deliver quality preventive services and help Americans more effectively use and benefit from those services. The investment in this activity supports health system and quality improvement changes such as electronic health records, systems to prompt clinicians and deliver feedback on performance, and requirements for reporting on outcomes such as control of high blood pressure and the proportion of the population up-to-date on chronic disease preventive services, as well as outreach to consumers to help reduce barriers to accessing these services.
  • Domain 4: Strategies to improve community programs linked to clinical services ensures that communities support and clinics refer patients to programs that improve management of chronic conditions. The investment in this activity addresses those with or at high risk for chronic diseases and facilitates access, referral and payment for quality community resources, to best manage their condition or disease. These supports include interventions such as clinician referral, community and school delivery and third-party payment for effective programs that increase the likelihood that people with high blood pressure, diabetes or prediabetes and other chronic conditions in school-age children such as asthma and food allergies will better manage their conditions.

CDC-recognized Lifestyle Change Programs
Organizations are recognized by the Centers for Disease Control and Prevention (CDC) to offer lifestyle change programs (CDC-recognized lifestyle change programs or CDC-recognized LCPs) for diabetes prevention, which is a key part of the National Diabetes Prevention Program. The lifestyle change program provides a trained lifestyle coach, a CDC-approved curriculum, and group support over the course of a year.

Chronic Disease Self-Management Programs (CDSMP)
Chronic disease self-management programs allow people with any chronic disease to participate and learn self-management skills. The program is a series of structured community based workshops or classes which hold participants accountable to goal setting. Participants learn about coping strategies, exercises, medication, communication skills, nutrition, decision making, and how to determine what approaches might be effective for them. Classes are highly participative, where mutual support and success build the participants’ confidence in their ability to manage their health and maintain active and fulfilling lives.

Clinical Quality Measure (CQM)
Tools that help measure and track the quality of healthcare services provided by eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) within our health care system

Community Care Team (CCT)
The Community Care Team is a multidisciplinary team that partners with primary care offices (certified health care homes), the hospital, and existing health and social service organizations. The goal is to provide citizens with the support they need for well-coordinated preventive health services and coordinated linkages to available social and economic support services.

Community Clinical Linkages ( also see CDC Chronic Disease Prevention and Health Promotion Domains)
Community clinical linkages help to connect health care providers, community organizations, and public health agencies to improve patients’ access to preventive and chronic care services. The goals of community clinical linkages include coordinating health care delivery, public health, and community-based activities to promote healthy behavior; forming partnerships and relationships among clinical, community, and public health organizations to fill gaps in needed services; and to promote patient, family, and community involvement in strategic planning and improvement activities. Types of community clinical linkages include coordinating services at one location, coordinating services between different locations, and developing ways to refer patients to resources.

Community Health Worker (CHW)
Community health workers are known by a variety of names. The CHWs section of the American Public Health Association describes CHWs as frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. The unique role of CHWs as culturally competent mediators (health brokers) between providers of health services and the members of diverse communities, as well as CHWs’ effectiveness in promoting the use of primary and follow-up care for preventing and managing disease, have been extensively documented and recognized for a variety of health care concerns, including hypertension and diabetes.

Community Pharmacists
Community pharmacists are health professionals accessible to the public. They supply medicines in accordance with a prescription or, when legally permitted, sell them without a prescription. Community-based pharmacists’ responsibilities include: checking and dispensing of prescription drugs, providing advice on drug selection and usage to doctors and other health professionals and counseling patients in health promotion, disease prevention and the proper use of medicines.

Consumer Assessment of Healthcare Providers and Systems (CAHPS)
The Consumer Assessment of Healthcare Providers and Systems develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care.

Critical Access Hospital (CAH)
A critical access hospital is a hospital certified under a set of Medicare Conditions of Participation (CoP), which are structured differently than the acute care hospital CoP. Some of the requirements for CAH certification include having no more than 25 inpatient beds; maintaining an annual average length of stay of no more than 96 hours for acute inpatient care; offering 24-hour, 7-day-a-week emergency care; and being located in a rural area, at least 35 miles drive away from any other hospital or CHA.

Daily Management of Chronic Conditions in School Settings
This term refers to a set of activities, actions, and protocols that collectively provide a safe and supportive environment in which the risk for an exacerbation of the chronic condition is reduced and/or eliminated. For example, establishing protocols for ensuring that daily, preventive, and/or quick-relief medications are available at school, when appropriate, and are taken as prescribed by a physician; educating students with a chronic condition about their condition and how to recognize and monitor symptoms; and providing appropriate modifications to the environment to reduce or eliminate exposure to substances that may initiate an exacerbation.

Department of Health and Human Services (HHS)
The Department of Health and Human Services is the U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The Centers for Disease Control and Prevention is an agency within HHS.

Diabetes Educator Practice Levels
The Practice Levels support the delivery of DSME/T within the framework of the AADE7 Self-Care Behaviors and The National Standards for Diabetes Self-Management Education and Support. The purpose of the practice levels is to increase access to DSME and achieve better patient care by:
  1. Delineating the roles and responsibilities of the multiple levels of diabetes educators and associate diabetes educators (for example, community health workers, medical assistants, etc.)
  2. Suggesting a career path for diabetes educators and associate diabetes educators
  3. Clarifying the contribution that can be made by individuals who have the knowledge, capability, diversity, and language skills needed to address diabetes self-management and support in a variety of settings

The AADE Guidelines for the Practice of Diabetes Self-Management Education and Training (DSME/T) describe the implementation of The Scope of Practice, Standards of Practice and Standards of Professional Performance for Diabetes Educators.

Diabetes Prevention Program (DPP)
The Diabetes Prevention Program (DPP) was a major multicenter clinical research study that showed that a structured lifestyle change program can reduce the risk for type 2 diabetes by almost 60% in people with prediabetes. DPP participants achieved a modest weight loss of 5-7% and were physically active at least 150 minutes a week.

Diabetes Self-Management Education and Training
Diabetes self-management education (DSME) and diabetes self-management training (DSMT) are used interchangeably and also combined as diabetes self-management education/training (DSME/T) to describe the ongoing process of facilitating the knowledge, skills, and abilities necessary for prediabetes and diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by evidence-based standards. The overall objectives of DSME/T are to support informed decision-making, self-care behaviors, problem solving, and active collaboration with the health care team in an effort to improve clinical outcomes, health status, and quality of life.

Diabetes Self-Management Program (DSMP)
Diabetes self-management program (DSMP) is the term for the program developed at Stanford University that uses lay health coaches to provide education and support to people with diabetes. DSMP, produced by the Stanford Patient Research Education Center, is a series of 2.5 hour workshops held for six weeks in a community setting. Classes are highly participative, where mutual support helps to build the participants’ confidence in their ability to manage their health and maintain active and fulfilling lives. DSMP can meet the National Standards for Diabetes Self-Management Education and Support if a qualified licensed individual maintains responsibility for supervising the lay leaders and is available to participants.

Diabetes Self-Management Support (DSMS)
DSMS are activities that assist a person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management training. The type of support provided can be behavioral, educational, psychosocial, or clinical.

Electronic Health (Medical) Record (EHR or EMR)
The electronic health (medical) record is a computerized medical file that contains the history of a patient’s medical care, commonly abbreviated as “EHR,” in contrast to “PHR,” which stands for personal health record. An EHR or EMR enables patients to transport their health care information with them at all times.

Eligible Provider as defined by CMS (EP)
Eligible providers are providers who are eligible for covered professional services paid under or based on the Medicare Physician Fee Schedule (PFS). Medicare eligible professionals include: doctor of medicine or osteopathy, doctor of dental surgery or dental medicine, doctor of podiatry, doctor of optometry, and chiropractor. Medicaid eligible professionals include: physician (primarily doctors of medicine and doctors of osteopathy), nurse practitioner, certified nurse-midwife, dentist, physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant. Medicaid EPs must meet one of the following criteria: have a minimum 30% Medicaid patient volume; have a minimum 20% Medicaid patient volume and is a pediatrician; practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals.

Federally Qualified Health Center (FQHC)
This term includes all organizations receiving grants under Section 330 of the Public Health Service Act. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors.

Health Care Extenders
Health care extenders, such as pharmacists, community health workers, and patient navigators help meet national health goals by conducting activities and interventions that promote health and prevent diseases and disability. Health care extenders work closely with patients and providers to control chronic illness through education and counseling, communication with providers, and, in some cases, medication titration.

Health Disparities
Health disparities are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes.

Health Electronic Record (HER)
Also known as EHR (electronic health record) or EMR (electronic medical record), a computerized medical file that contains the history of a patient’s medical care

Health Information Technology (HIT)
Computer-based tools developed specifically for health care delivery

Health Plan Employer Data and Information Set Measures (HEDIS)
A set of health care quality measures designed to help purchasers and consumers determine how well health plans follow accepted care standards for prevention and treatment

Health Resources and Services Administration (HRSA)
The Health Resources and Services Administration is an agency of the U.S. Department of Health and Human Services and is the primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable.

Hemoglobin A1c (HBA1c)
The hemoglobin A1c test, also called HbA1c, glycated hemoglobin test, or glycohemoglobin, is an important blood test that shows how well your diabetes is being controlled. Hemoglobin A1c provides an average of your blood glucose control over the past 3 months and is used along with home blood sugar monitoring to make adjustments in your diabetes medicines.

HIPAA Privacy Rule
Protects the privacy and security of individually identifiable health information kept by covered entities (e.g., a health care provider)

Hypertension (HTN) or High Blood Pressure (HBP)
HTN or HBP is a common condition in which the force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. It is usually indicated by an adult systolic blood pressure of 140mm Hg or greater or a diastolic blood pressure of 90mm Hg or greater.

Indian Health Service (IHS) Division of Diabetes Treatment and Prevention (DDTP)
The IHS DDTP provides information and resources to strengthen clinical, public health, and community approaches to diabetes treatment and prevention throughout the United States. The Division also plays a central role in managing and supporting the Special Diabetes Program for Indians (SDPI) by:
  • Translating and disseminating the latest science to Indian Health Service, Tribal, and Urban Indian health programs across the country;
  • Providing training on diabetes science and SDPI program management;
  • Facilitating the sharing of information and expertise among health care professionals and Tribal communities;
  • Supporting grant program efforts to use best practices in diabetes treatment and prevention; and,
  • Providing essential clinical data for program planning and improvement through the Diabetes Care and Outcomes Audit.

Informed Decision-Making (IDM)
Informed decision-making is a term to describe a process designed to help patients understand the nature of the disease or condition being addressed; understand the clinical service being provided including benefits, risks, limitations, alternatives and uncertainties; consider their own preferences and values; participate in decision-making at the level they desire; and make decisions consistent with their own preferences and values or choose to defer a decision until a later time.

Institute for Healthcare Improvement (IHI)
IHI is an independent not-for-profit organization based in Cambridge, Massachusetts. IHI is a leading innovator in health and health care improvement worldwide.

Institute of Medicine (IOM)
An independent, non-profit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
An independent, not-for-profit group in the United States that administers accreditation programs for hospitals and other healthcare-related organizations

Lay Health Worker
Lay health workers have no formal professional education but they are usually provided with job-related training. They can be involved in either paid or voluntary care. They perform diverse functions related to health care delivery and a range of terms are used to describe them including community health workers, community volunteers, and peer leaders among others.

Meaningful Use (MU)
The Recovery Act specifies the following 3 components of Meaningful Use: use of certified EHR in a meaningful manner (e.g., e-prescribing), use of certified EHR technology for electronic exchange of health information to improve quality of health care, use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary.

Medically Underserved Areas/Populations (MUAs/MUPs)
Medically Underserved Areas/Populations are areas or populations designated by the Health Resources and Services Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty or a high elderly population.

Medication Therapy Management
Medication therapy management is a service or group of services that optimize therapeutic outcomes for individual patients. Medication therapy management services include medication therapy reviews, pharmacotherapy consults, anticoagulation management, immunizations, health and wellness programs and many other clinical services. Pharmacists provide medication therapy management to help patients get the best benefits from their medications by actively managing drug therapy and by identifying, preventing and resolving medication-related problems.

National Committee for Quality Assurance (NCQA)
A national organization that accredits quality assurance programs in prepaid managed health care organizations

National Council on Aging (NCOA)
The National Council on Aging (NCOA) is a national organization with a mission to improve the lives of millions of older adults, especially those who are struggling. NCOA is partnering with nonprofit organizations, government, and business to improve the health and economic security of 10 million older adults by 2020 through innovative community programs and services, online help, and advocacy.

National Diabetes Prevention Program (National DPP)
The National DPP is an initiative to provide cost effective interventions in communities to prevent type 2 diabetes. This public-private partnership brings together community-based organizations, health insurers, employers, healthcare systems, academia, and government agencies. A key part of the National DPP is a lifestyle change program that provides a trained lifestyle coach, a CDC-approved curriculum, and group support over the course of a year. The National DPP puts in place all the elements needed for large-scale implementation of this effective lifestyle intervention across the nation to reduce the incidence of type 2 diabetes. The four parts of CDC’s approach to the National DPP are: training, the CDC Diabetes Prevention Recognition Program (DPRP), lifestyle change program sites and payment model, and health marketing.

National Institutes of Health (NIH)
The National Institutes of Health is a part of the U.S. Department of Health and Human Services and is the primary federal agency for conducting and supporting medical research.

National Quality Forum (NQF)
A not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting

National Standards for Diabetes Self-Management Education and Support
National Standards for Diabetes Education and Support were designed to define quality diabetes self-management. The Standards are designed to define quality DSME and support and to assist diabetes educators in providing evidence-based education and self-management support. The Standards are reviewed and revised approximately every 5 years by key organizations and federal agencies within the diabetes education community. Organizations seeking Medicare reimbursement must meet the National Standards.

Patient-Centered Care
Care that considers patients’ cultural traditions, their personal preferences and values, their family situations and their lifestyles

Patient Centered Medical Home (PCMH)
PCMH is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs and can improve patients’ and providers’ experience of care.

Patient Protection and Affordable Care Act (PPACA)
The Patient Protection and Affordable Care Act is the full title of the comprehensive health care reform law enacted in March 2010.

Pay-for-Performance (P4P)
Pay-for-performance is a method for paying hospitals and physicians based on their demonstrated achievements in meeting specific health care quality objectives. The idea is to reward providers for the quality – not the quantity – of care they deliver.

Peer Leaders
Peer leaders are people with diabetes who have undergone intensive training to provide self-management support to others living with diabetes.

Performance Improvement (PI)/Quality Improvement (QI)
In health care, PI refers to the use of concurrent systems to improve quality. PI programs usually use tools such as task forces, statistical studies, cross-functional teams, process charts, etc.

Physician Hospital Organization (PHO)
A physician-hospital organization is a joint venture between one or more hospitals and a group of physicians. It acts as the single agent for managed care contracting, presenting a united front to payers. In some cases, the PHO provides administrative services, credentials physicians and monitors utilization.

Physician Quality Reporting System (PQRS) (formerly Physician Quality Reporting Initiative (PQRI))
A program that provides a financial incentive to physicians and other eligible professionals who successfully report quality data related to covered services provided under the Medicare Physician Fee Schedule

Plan Do Study Act Cycle (PDSA Cycle)
A component of the Model for Improvement which involves testing changes on a small scale before full implementation, a quality improvement tool
  • Plan – a specific planning phase
  • Do – a time to try the change and observe what happens
  • Study – an analysis of the results of the test
  • Act – devising next steps based on the analysis

Priority Populations
High risk, high burden populations are referred to as “priority populations” and are those population subgroups with pre-diabetes or uncontrolled high blood pressure who experience racial/ethnic or socioeconomic health disparities including inadequate access to care, poor quality of care, or low income.

Quality Improvement Organization (QIN)
Designated by CMS, QINs work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly among under-served populations.

Regional Extension Center (REC)
An organization that has received funding under the Health Information Technology for Economic & Clinical Health Act to assist health care providers with the selection and implementation of electronic health record technology

Return on Investment (ROI)
A return on investment (ROI) is the amount of improvement in care brought about by a certain investment. ROI can also refer to the theory that if you invest in health care quality now, then the quality of care for patients will improve in the future.

Self-Measured Blood Pressure Monitoring (SMBP)
SMBP, or home blood pressure monitoring, is the regular measurement of blood pressure by a patient at home or outside the clinic setting using a personal home measurement device.

State Innovation Models (SIM) Initiatives
The State Innovation Models Initiative is providing up to $300 million to support the development and testing of state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states.

Team-Based Health Care
Team-based health care is defined as the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care. Principles of Team-based Care include:
  • Shared goals
  • Clear roles
  • Mutual trust
  • Effective communication
  • Measurable processes and outcomes

The use of electronic communication networks for the transmission of information and data focused on health promotion, disease prevention, and the public’s overall health including patient/community education and information, population-based data collection and management, and linkages for health care resources and referrals

The practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and health education, using interactive audio, video, or data communications

Triple Aim
The Institute for Healthcare Improvement Triple Aim is a framework that describes an approach to optimizing health system performance. The term “Triple Aim” refers to the simultaneous pursuit of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.

Uniform Data System (UDS)
Contains the annual reporting requirements for recipients of the cluster of primary care grants funded by the Health Resources and Services Administration (HRSA)

U.S. Centers for Disease Control and Prevention (CDC)
CDC is one of the major operating components of the Department of Health and Human Services. Its mission is to collaborate to create the expertise, information, and tools that people and communities need to protect their health.

Value-Based Purchasing (VBP)
Value-based purchasing is a broad strategy used by some large employers to get more value for their health care dollars by demanding that health care providers meet certain quality objectives or supply data documenting their use of best practices and quality treatment outcomes.

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