Delivery System Design Tools and Links

Assure the delivery of effective, efficient clinical care and self-management support

• Define roles and distribute tasks among team members
• Use planned interactions to support evidence-based care
• Provide clinical case management services for complex patients (2003 refinement)
• Ensure regular follow-up by the care team
• Give care that patients understand and that fits with their cultural background (2003 refinement)

Diabetes

• Diabetes Patient Invitation Letter (20 KB - MS Word)
  Letter from provider to patient informing them of the Collaborative and inviting them for a diabetes visit
• Chronic Disease Documentation Set (External Site)
  Paper chart flow sheets
• Diabetes Nursing Visit (176 KB - MS Word)
  Form for use in diabetes nursing visits.
• Diabetes Progress Note (180 KB - MS Word)
  Progress note form for use in diabetes office visits.
• Medical Record Form for Diabetes Visit (231 KB - PDF)
  Form for use in diabetes office visits.
• Standing Orders - Patients With Diabetes (35 KB - MS Word)
  Standing orders for labs and tests for diabetes office visits.
• Standing Orders - Adult Patients With Diabetes (30 KB - MS Word)
  Standing orders for labs and tests for diabetes office visits.
• Tools for Medical Practices and Clinics (External Site)
  Office procedures for diabetic foot exams; chronic disease documentation set (flowsheets for chart); foot specialist consult request form; foot specialist consult report form; foot exam chart stickers; patient-education materials about foot exams (brochures and posters in English and Spanish); eye exam flyers in English, Chinese, and Korean; list of monofilament suppliers

Depression Screening

• Screening for Depression: What's new from the US Preventive Services Task Force (External Site)
  This fact sheet presents highlights of the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for depression.
• MacArthur Foundation's Initiative for Depression in Primary Care (External Site)
  The mission of the Initiative on Depression and Primary Care is to enhance the ability of primary care clinicians to recognize and manage depression.

Foot Exam

• Diabetic Foot Screen Form - Alaska (56 KB - MS Word)
  Form for foot examination and documentation.
• National Diabetes Education Program Foot Exam Materials (External Site)
  “Feet Can Last a Lifetime” provider kit of materials.

Eye Exam

• Eye Exam Referral Form from VFC (178 KB - MS Word)
• Eye Examination materials for patients in three languages.
  • English Version (1,936 KB - PDF)
  • Chinese Version (919 KB - PDF)
  • Korean Version (934 KB - PDF)
• Eye MD Examination Report Form - Document Template (157 KB - MS Word)
  American Academy of Opthalmology Eye Exam report form
• Eye MD Referral Form Document Template (104 KB - MS Word)
  American Academy of Ophthalmology Eye Exam Referral Form
• Eye Fax Sheet - Notice of Diabetic Eye Status (22 KB - MS Word)
  Eye exam results reporting form

Gestational Diabetes

• Medline Plus information in Spanish (External Site)
  Spanish language information about Gestational Diabetes
• AAFP Patient Information (External Site)
  American Academy of Family Practice information on Gestational Diabetes.
• "Taking Care of Gestational Diabetes" booklets in English and Spanish, International Diabetes Center (External Site)
  Park Nicollett (International Diabetes Center) materials on Gestational Diabetes.

Flu and Immunizations

• Immunization Action Coalition (IAC): Adults Only Vaccination: A Step-by-Step Guide (External Site)
  Adult immunization information
• Immunization Action Coalition of Washington (IACW) Tetanus/Diphtheria Vaccination Campaign (114 KB - PDF)
  Tetanus and Diptheria immunization information.
• Immunization Standing Order Form (22 KB - MS Word)
  Standing order form from Pacific Medical Center
• Adult Immunization Schedule (External Site)
  Printable adult immunization schedule for 05-06
• Gallery of Patient-Education Material, Flu Season 2003 - 2004 (External Site)
  Available in English and Spanish.
• Immunization information in Spanish (External Site)
  CDC Spanish language immunization information

Planned/Group Visits

• Group Visit Starter Kit (112 KB - MS Word)
  Group visit kit from ICIC with forms and tools.
• Group Visits for Chronic Illness Care (External Site)
  Models, Benefits and Challenges (article from the American Academy of Family Practice). With proper planning, group visits can expand your options for managing the care of chronically ill patients.
• Planned Visits
• Medicaid Reimbursement for Group Visits for Clients with Diabetes or Asthma (39 KB - MS Word)
  Washington Medicaid billing instructions for diabetes and asthma group visits.
• Diabetes Visit Worksheet (22 KB - MS Word)
  Worksheet for patient and provider input at group visits
• Planned Visit Checklist (21 KB - MS Word)
  Content list for planned visits.
• Nursing & Receptionist Checklist (23 KB - MS Word)
  Checklist for planned visits.
• Diabetes Self Management Goals (50 KB - MS Word)
  Goal setting sheet for diabetes patients.
• Diabetes Nursing Visit Worksheet (54 KB - MS Word)
  Documentation for nursing visit for diabetes patients
• Diabetes Monitoring Protocol and Standing Order (41 KB - MS Word)
  Standing order form for diabetes patients
• Hemoglobin A1c Equivalents (35 KB - MS Word)
  Table of average blood glucose levels based on HbA1c test results.

Smoking Cessation

• Smoking Cessation Referral Tool (30 KB - MS Word)
  Harborview used to this tool for nurses, patients or providers to determine, based on the patients outpatient care location, the most appropriate smoking cessation program.
• Smoking Cessation Screening Tool (14 KB - PDF)
  Screening questions for assessing a patients stage of "readiness to quit."
• Tobacco Cessation in Spanish from the Centers for Disease Control (External Site)
  Spanish language information from the CDC
• Helping Smokers Quit (External Site)
  A Guide for Nurses from AHRQ (Agency for health research and quality)

Various external sites for delivery system design information

• National Cancer Institute (External Site)
  Free publications available in various languages
• Weight Control Information Network (NIDDK) (External Site)
  Up-to-date, science-based information on weight control, obesity, physical activity, and related nutritional issues.
• Nurse Case Management to Improve Glycemic Control Article (External Site)
  Article from the annals of internal medicine
• A Population-Based Approach to Diabetes Management in a Primary Care Setting (External Site)
  Article from the American college of physicians authored by Ed Wagner, MD, MPH
• Planning Group Visits for High Risk Patients (External Site)
  Article from the American Academy of Family Physicians

Links to external resources are provided as a public service and do not imply endorsement by the Washington State Department of Health.

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Documents posted in .pdf version on the Department of Health Web site will be made available in an alternative format on request to users who are unable to download or view .pdf files on the Web. To request an alternative format, contact Gary Holt.