Glossary of Terms and Acronyms

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1115 Demonstration Waiver
A process instituted by CMS to allow states to institute reforms that go beyond routine medical care and focus on evidence-based interventions that drive better health outcomes and quality of life improvements.

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.

Advanced Training or Advanced Skills Training for Lifestyle Coaches
Training beyond the initial training requirements described in the Diabetes Prevention Recognition Program (DPRP) Standards.

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.

Bi-Directional E-Referral System
A bi-directional e-referral system supports information going from the health care system to a specified community program or resource (e.g., a CDC-recognized lifestyle change program) and information returning from that program to the health care system. Ideally, bi-directional referral systems are integrated within the electronic health record (EHR). Bi‐directional referrals help “close the loop”, since CDC-recognized organizations are able to communicate with the provider using an electronic platform.

Care Practices
The process and delivery of care, in this case for persons with diabetes. Appropriate diabetes-related care practices should align with evidence-based clinical guidelines such as the American Diabetes Association’s Standards of Medical Care in Diabetes.

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
A key component of the National DPP is a structured, evidence-based, year-long lifestyle change program to prevent or delay onset of type 2 diabetes in adults with prediabetes or at risk of developing type 2 diabetes (1). The lifestyle change program is group-based, facilitated by a trained lifestyle coach, and uses a CDC-approved curriculum. The curriculum incorporates regular opportunities for direct interaction between the lifestyle coach and participants, builds peer support, and focuses on behavior modification through healthy eating, increasing physical activity, and managing stress. The program may be delivered in-person, online, or through a combination of both delivery modes.

CDC-Recognized Organization
An organization that has demonstrated its ability to effectively deliver a proven type 2 diabetes prevention lifestyle change program and has applied for and received CDC recognition from the DPRP.

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 Decision Support (CDS)
Clinical decision support provides clinicians, staff, patients, and others with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. They require computable biomedical knowledge, person-specific data, and a reasoning or inferencing mechanism that combines knowledge and data to generate and present helpful information to clinicians as care is being delivered. This information must be filtered, organized, and presented in a way that supports the current workflow, allowing the user to make an informed decision quickly and take action. The majority of CDS applications operate as components of comprehensive EHR systems, although stand-alone CDS systems are also used.

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.

Collaborative Practice Agreements (CPAs)
A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions.

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)
CHWs are known by a variety of names (see: https://www.cdc.gov/dhdsp/docs/chw_brief.pdf). As defined by the CHW section of the American Public Health Association, CHWs are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as liaisons, links, or intermediaries between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. One of the most important features of CHWs is that these women and men strengthen already existing ties within their communities.

Community Health Worker (CHW) Certification
Certification is intended to ensure that CHWs have met key training requirements. The administrative oversight provided and the training and certification processes and requirements for CHWs vary considerably between states. Some have state-regulations determining training and certification requirements for CHWs that must be met in order to practice and receive reimbursement for CHW services.

Community Health Worker (CHW) Covered Services
Services ordered by a licensed provider to be provided by a CHW. These services frequently include providing health education to individuals and groups in conjunction with a health care team. Services can occur face-to-face with recipients (individually or in a group) in an outpatient clinic, hospital, client’s home, or other community setting. The content of the education or training should be based on a standardized curriculum consistent with established or recognized health standards. It is worth noting that a standardized self-management, skill-building curriculum may also be required for related CHW administrative tasks such as documentation, phone outreach, and coordination of community resources or other enabling services in order for the CHWs to be reimbursed. It is also important to ensure that the curriculum can be modified to meet clinical needs, cultural norms, and health literacy levels. Examples of CHW covered services can be found in the policy brief developed by CDC’s Division for Heart Disease and Stroke Prevention, Addressing Chronic Disease through Community Health Workers, and in the technical assistance guide, States Implementing CHW Strategies. These and other resources can be found in the following CHW Toolkit: https://www.cdc.gov/dhdsp/pubs/toolkits/chw-toolkit.htm.

CHW Payment Mechanisms
This broadly refers to the means by which CHW services are financially reimbursed. For example, in January 2014, the Centers for Medicare & Medicaid Services (CMS) created a final rule (CMS-2334-F), Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligible Notices, Fair Hearings and Appeal Process, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment, which opened up payment opportunities for preventive services by non-licensed individuals and offers potential for CHW reimbursement under Medicaid.

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.

Covered Benefit
A health service included in the premium of a health insurance policy paid by or on behalf of the enrolled individual (also called benefit or covered service). For the purpose of this strategy, this is employer-provided insurance covering the National DPP lifestyle change program. A covered benefit is a more sustainable way to offer preventive services than a wellness program.

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.

Designated Marketing Area (DMA)
A region where the population receives the same media offerings (radio, television, newspapers, etc.). Understanding your audiences’ media market helps you make decisions about your promotion strategy, such as where to place advertising.

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 Prevention Recognition Program (DPRP)
The Division of Diabetes Translation manages the DPRP, which is the quality assurance arm of the National DPP. The DPRP awards CDC-recognition to organizations delivering the lifestyle change program that are able to meet national quality standards and achieve the outcomes proven to prevent or delay onset of type 2 diabetes.

Diabetes Prevention Recognition Program (DPRP) Retention Standards
For preliminary and full recognition, organizations must average 9 sessions in months 1-6 and 3 sessions in months 7-12 for participants in a given six month evaluation cohort.

Diabetes Self-Management Education and Support (DSMES)
The ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.

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)
The support that is required for implementing and sustaining coping skills and behaviors needed to self-manage diabetes on an ongoing basis.

Diabetes self-management training (DSMT)
The Centers for Medicare & Medicaid Services (CMS) uses the term “training” (DSMT) instead of “education and support” (DSMES) when defining the reimbursable benefit. This term relates specifically to Medicare billing.

DSMES Recognition and accreditation
Recognition and accreditation help ensure that DSMES services offer quality education. CMS has authorized two organizations, the ADA and AADE, to grant recognition or accreditation for DSMES. ADA uses the term recognition, while AADE uses the term accreditation. The two terms essentially involve similar processes to evaluate DSMES services. Both organizations rely on the 2017 National Standards for Diabetes Self-Management Education and Support (2017 National DSMES Standards).

Diagnostic Testing
The use of a clinical test to establish the presence (or absence) of disease as a basis for treatment decisions in symptomatic individuals, or those who screen positive on a risk test. CKD is diagnosed by the presence of either of the following two indicators for at least 3 months (Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group, 2012):

  1. Markers of kidney damage (one or more): Albuminuria (AER ≥30 mg/24 hours; ACR ≥30 mg/g [≥3 mg/mmol]) - Urine sediment abnormalities - Electrolyte and other abnormalities due to tubular disorders - Abnormalities detected by histology - Structural abnormalities detected by imaging - History of kidney transplantation
  2. Decreased glomerular filtration rate (eGFR): eGFR < 60 ml/min/1.73 m2

Digital Health
The broad scope of digital health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine.

Electronic Health (Medical) Record (EHR or EMR)
  1. Electronic Health Record (EHR):
    An EHR is an electronic version of a patient’s medical history that is maintained by a health care organization/provider over time. EHRs include key administrative and clinical data relevant to an individual’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
  2. Electronic Medical Record (EMR):
    A digital version of a patient’s chart in the health care provider’s (HCP) office. An EMR contains the medical and treatment history of the patient in one practice.

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.

Enabling Services (ES)
Enabling services (ES) are non‐clinical services that support the delivery of basic health care and facilitate access to comprehensive medical and social services. They include case management, benefit counseling or eligibility assistance, health education and supportive counseling, interpretation, outreach, transportation, and education of patients and the community regarding the availability and appropriate use of health services. Community Health Workers (CHWs) can be engaged to deliver these enabling services and to serve as advocates and health guides for clients with prediabetes. For more information, visit http://enablingservices.aapcho.org.

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.

Formal Training
Training conducted by one of the following methods: (1) a training entity that has a Memorandum of Understanding with CDC and is listed on the CDC website; (2) a private organization with a national network of program sites; (3) a CDC-recognized virtual organization with national reach; or (4) a Master Trainer. The recommended minimum length of formal training for new Lifestyle Coaches is at least 12 hours or two days.

Fully-Insured Employer
A fully-insured health plan is the traditional way to structure an employer-sponsored health plan. The employer pays a predetermined premium to the insurance carrier. The premium rates are fixed for a year, based on the number of employees enrolled in the plan each month. The insurance carrier assumes the financial risk for providing all contracted health care benefits.

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 Communication
Approaches that will help "get the word out."

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 Literacy
Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. An individual may be literate but unable to comprehend, either verbally or in writing, complicated health care terminology (“jargon”). While most individuals who are not trained health care providers have some degree of health illiteracy, this is an especially difficult issue for individuals who do not speak English and for older or less well educated adults. These difficulties can be further compounded when individuals are illiterate (do not know how to read or write in their spoken language). The Agency for Healthcare Quality Improvement (AHRQ) and the Health Resources and Services Administration (HRSA) have developed resources and training to improve awareness and knowledge among health care providers of the three main factors that affect communication with patients: health literacy, cultural competency, and low English proficiency (LEP).

Health Marketing
Approaches that help address structural, environmental, and interpersonal issues that affect behavior.

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.

High Burden Population
A population affected disproportionately by high blood pressure, high blood cholesterol, type 2 diabetes, or prediabetes due to socioeconomic or other characteristics, including inadequate access to care, poor quality of care, or low income.

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.

The ability of different health information technology systems to seamlessly communicate and exchange data.

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.

Lifestyle Coach
A trained individual who facilitates the yearlong National DPP lifestyle change program (See also: Formal Training; Advanced Training; Master Trainer (see also Advanced Training).

Master Trainer
An individual who has completed at least 12 hours of formal training as a Lifestyle Coach, has successfully offered the National DPP lifestyle change program for at least one year, and has completed a Master Trainer program offered by a training entity listed on the CDC website.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which calculated payment cuts for clinicians participating in Medicare. For eligible clinicians, the Quality Payment Program provides new tools and resources.

Meaningful Use (MU)
Term is redefined under MACRA, see: https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use-and-macra
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.

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.

Medicaid Managed Care Organizations (MCOs)
Private organizations that contract with health care providers in a state to deliver specific services to Medicaid beneficiaries under the state’s State Medicaid Plan. MCOs operate on a capitated basis, meaning they are reimbursed on a per-capita basis per beneficiary. If the costs of providing care to a beneficiary are over the capitation fee, the MCO is responsible for absorbing the overage. If the costs of providing care to a beneficiary are below the capitation fee, the MCO retains the excess as profit. (MCOs are also reimbursed for administrative costs and care management in addition to specific health care costs).

Medicaid State Plan and State Plan Amendment
Every state is required to file a Medicaid State Plan with the Centers for Medicare & Medicaid Services (CMS). If the state wants to make a change to its Medicaid program by altering the services covered (within federal guidelines), or the populations covered, it must submit a State Plan Amendment.

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 Management
Medication Management is used by doctors and pharmacists to ensure that patients are achieving optimal therapeutic outcomes for the prescription medications they may be taking. Medication Management is used to cover a broad range of professional activities, such as: o Performing patient assessments or a comprehensive review of prescriptions and their possible interaction or side effects. o Formulating both short and long term medication treatment plans. o Monitoring the safety and efficacy of any and all prescription medication plans. o Ensuring directional or instruction-based compliance through patient education. o Ensuring better documentation and communication between health providers in order to maintain a high standard of care between medical professionals.

Merit-based Incentive Payment System (MIPS)
MIPS is part of an effort to better connect care quality with Medicare payments and is one of the two tracks in the Quality Payment Program (QPP), which implements provisions of MACRA. MIPS includes four connected pillars that affect how Medicare pays clinicians: Quality, Improvement Activities, Advancing Care Information, and Cost.

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.

Online Programs Online programs are delivered 100% online for all participants. Participants log into course sessions via a computer, laptop, tablet, or smart phone. Participants also must interact with Lifestyle Coaches at various times and by various communication methods.

Participant Retention
Participants who are engaged and regularly and consistently attending weekly, biweekly, and monthly sessions, especially in months 7-12.

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. Similarly, value-based care rewards health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of a larger quality strategy to reform how health care is delivered and paid for.

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.

Pharmacists' Patient Care Process
Pharmacists use a patient-centered approach in collaboration with other providers on the health care team to optimize patient health and medication outcomes.

The process is focused on 5 steps:

  1. Collect: The pharmacist assures the collection of the necessary subjective and objective information about the patient in order to understand the relevant medical/medication history and clinical status of the patient.
  2. Assess: The pharmacist assesses the information collected and analyzes the clinical effects of the patient’s therapy in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care.
  3. Plan: The pharmacist develops an individualized patient-centered care plan, in collaboration with other health care professionals and the patient or caregiver, which is evidence-based and cost-effective.
  4. Implement: The pharmacist implements the care plan in collaboration with other health care professionals and the patient or caregiver.
  5. Follow up: The pharmacist monitors and evaluates the effectiveness of the care plan and modifies the plan in collaboration with other health care professionals and the patient or caregiver as needed.

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.

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

Prediabetes is a health condition where blood sugar levels are higher than normal, but not high enough for a diagnosis of type 2 diabetes. Prediabetes increases an individual’s risk for type 2 diabetes and cardiovascular disease.

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 (QIO)
The QIO Program is part of the DHHS National Quality Strategy for providing better care and better health at lower cost. There are two types of QIOs that work under the direction of the Centers for Medicare & Medicaid Services in support of the QIO Program: Beneficiary and Family Centered Care (BFCC)-QIOs and Quality Innovation Network (QIN)-QIOs.

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.

Reimbursement usually means receiving money in repayment for money already spent or an expense already incurred. In this context, reimbursement means that CHWs are paid for the services they perform.

As you consider reimbursement for CHWs, consider the following:
  • Including CHW services in Medicaid administrative cost claims.
  • Integrating CHWs into managed care or team-based care models.
  • Providing tools for motivating private insurers to engage CHWs.

Reminders (Alerts)
Reminders are a type of alert triggered by particular parameters (e.g. time and date, high/low threshold, or clinical indication) usually presented as highlighted text or a pop-up that requires action. Reminders serve to cue clinicians that certain events should take place, but have not yet done so. Reminders are regularly used in primary care systems, particularly with respect to the management of patients with chronic conditions that require regularly scheduled repetitive tasks.

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.

Screening involves the examination of a group of asymptomatic individuals to identify those with a high probability of having or developing a given disease, typically by means of an inexpensive diagnostic test (National Institutes for Health). Currently, the ADA Type 2 Diabetes Risk Test is the recommended screening tool for prediabetes. Individuals who score 5 or higher on the risk test should follow up with their health care providers for a blood glucose test.

Self-Insured Employer
The employer assumes the financial risk for providing health care benefits to its employees. Self-insured employers may still contract with an insurance carrier to handle the administrative aspects of the claims process. (This is also called an Administrative Services Only [ASO] health care plan.)

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. When combined with clinical support (e.g., one-on-one counseling, web-based or telephonic support tools, education), this Domain 3 strategy can enhance the quality and accessibility of care for people with high blood pressure and improve blood pressure control.

Social Determinants of Health
Conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.

State Innovation Models (SIM) Initiatives
The State Innovation Models Initiative is providing more than $622 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.


The Center for Public Health Systems Science at the Brown School, Washington University in St. Louis, defines sustainability capacity as the ability to maintain programming and its benefits over time. To improve capacity for sustainability, it suggests that organizations strengthen the structures and processes that exist within their programs to ensure that they can strategically leverage resources to weather the changes and challenges that will come their way. Relative to CHWs, sustainability ensures that a CHW program is structured and financed to provide services over time.

The Rural Health Information Hub, supported by the Health Resources and Services Administration, suggests that there are three critical issues linked to the sustainability of CHW programs:
  1. evaluation,
  2. financing,
  3. and credentialing
Team-Based Care
Team-based 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 Health Resources and Services Administration (HRSA) defines telehealth as: “The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.” Telehealth may be used to expand reach and may lower the cost of services, potentially increasing service to underserved populations.

Telehealth Delivery Methods
  1. Live video (synchronous) – Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology. This type of service is also referred to as “real-time” and may serve as a substitute for an in–person encounter when it is not available.
  2. Store and Forward (asynchronous) — Transmission of recorded health history (pre-recorded videos and digital images such as x–rays and photos) through a secure electronic communications system to a practitioner, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.
  3. Remote Patient Monitoring – Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support.
  4. Mobile Health – Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDA's.

The American Telemedicine Association (ATA) defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, smart phones, wireless tools, and other forms of telecommunications technology.

Testing for Prediabetes
For those whose risk test score is elevated, conduct a blood test using one of the three tests described in the Diabetes Prevention Recognition Program (DPRP) Standards:
  • Fasting glucose of 100 to 125 mg/dl
  • Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  • A1c of 5.7 to 6.4

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.

Umbrella DSMES ADA-recognized/AADE-Accredited Service
A DSMES service where an agency serves as the sponsoring organization to secure ADA-recognition or AADE-accreditation, managing all the certification requirements, while other agencies serve as multi-sites or branch sites to deliver DSMES.

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.

Wellness Benefits/Wellness Programs
Wellness benefits are benefits offered by an employer or health plan to improve and promote employee health and fitness. The employer or health plan generally offers premium discounts, cash rewards, gym memberships, and other incentives to encourage employees to participate. Wellness benefits are not a part of a health insurance program. For the purpose of this strategy, the employer may offer the National DPP lifestyle change program in several ways:
  1. by contracting with a CDC-recognized organization to offer the lifestyle change program at the worksite,
  2. by subsidizing employee participation in community-based CDC-recognized organizations,
  3. or by applying for CDC recognition to offer the lifestyle change program directly. While employers generally fund wellness programs with discretionary dollars, these programs can help build long-term sustainable support for the lifestyle change program by demonstrating successful outcomes.

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