1. We Are the Heart of the Community Diabetes Self Management Education Program (DSME)

2. What is DSME? We Are the Heart of the Community CAHN’s DSME program is a comprehensive diabetes education program that provides didactic education, nutritional information and exercise instruction for those in the community who live with diabetes, who have pre-diabetes or have a loved one with diabetes.

3. Program Information CAHN’s DSME program was recognized by the ADA in December 2010. CAHN has also been awarded PCMH level 3 distinction This is important because it allows the DSME program to utilize internal resources for the program including Mental Health and Dental services. Provides diabetes nurse case management Provides diabetes group classes Provides community resources and support We Are the Heart of the Community

4. DSME 1:1 Case Management Process begins with a provider referral CAHN has 6 clinical sites and it’s providers are able to enter DSME referrals electronically through our EMR. Non-CAHN patient’s are required to obtain a referral from their PCP prior to enrollment. Providers specify whether the patient requires 1:1 DSME, group sessions or both Nurse Case Managers schedule the appointments and/or enroll them into the DSME program We Are the Heart of the Community

5. DSME 1:1 sessions We Are the Heart of the Community Each patient completes an initial assessment utilizing tools from the AADE and AADE7 electronic documentation system. An individual diabetes management plan is established including exercise, nutrition and medication management. Patients are followed until established goals are met or until insurance session limits are met. A continuous working relationship with the patient’s provider is required to ensure the best outcomes for the patient.

6. DSME Group Sessions Begins with either a PCP referral or a patient self referral. Groups are offered quarterly in 10 week cohorts. Cohorts include diabetes education, exercise and nutritional counseling. CAHN utilizes its internal resources to assist with the program. For example CAHN’s Mental Health professionals conduct the DSME sessions on “Depression and Diabetes”. We Are the Heart of the Community

7. Group specifics We Are the Heart of the Community The first 60 minutes of class is comprised of intake: Vital signs (BP, Hemoglobin A1C and Weight) The second hour of class is divided into 30 minute increments An exercise instructor presents exercise techniques and participants are able to get 30 minutes of aerobic exercise. This may include low impact aerobics, chair exercises or even line dancing. The final 30 minutes of class time is spent discussing nutrition. Because CAHN has a relationship with the Food Bank, we are able to provide a healthy meal prepared by a nutritionist. We are also able to provide some of the ingredients used to prepare the meal for the participants to go home with.

8. Group specifics cont… At the end of 10 weeks, each participant takes part in a graduation ceremony. This includes Graduation certificates Celebratory meal Graduation gifts We Are the Heart of the Community

9. Service Fees DSME classes are offered free of charge and are open to anyone interested. DSME 1:1 sessions are billable services We offer special slide scale payment options for self-pay patients. We Are the Heart of the Community

10. How is Success Measured? The success of CAHN’s DSME program is measured using the following quality indicators/tools: Pre and Post BMIs Pre and Post participant weights Pre and Post AlCs Pre and Post program behavior surveys We Are the Heart of the Community

11. Conclusion It is our hope that through the DSME program at CAHN we will: Inspire and encourage communities to consider newer, innovative ways to tackle some of our most pressing health concerns. Decrease the health disparity that exists in our communities by providing state of the art health educational programs. Encourage a more interactive patient/provider relationship. Help to decrease the propensity of diabetes and it’s complications in our communities. We Are the Heart of the Community

12. Questions??? THANK YOU!!! We Are the Heart of the Community

13. OUR LOCATIONS Vernon J. Harris Medical and Dental Center 719 N. 25th Street Richmond, VA 23223 Bermuda Medical Center 2740 Bensley Commons Blvd. North Chesterfield, VA 23237 Glenwood Medical and Dental Center 2711 Byron Street Richmond, VA 23223 Main Street Medical Center 2025 E. Main Street, Suite 7 Richmond, VA 23223 Southside Medical Center 101 Cowardin Ave., Suite 102 Richmond, VA 23224 Northside Medical Center 2809 North Ave. Richmond, VA 23222 We Are the Heart of the Community