Improving Diabetes Self-Management and Coordination of Care Among SASH Participants

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Introduction: SASH (Support and Services at Home) coordinates the resources of social service agencies, community health providers and nonprofit housing organizations to support Vermonters who choose to live independently at home. Currently, SASH does not have a way by which they monitor participant’s diabetes management. Aims of this project: 1. Improve diabetes management among SASH participants with a Diabetes Self-Management Tool; 2. Provide SASH Wellness nurses tools for education of newly diagnosed diabetics.

Methods: The Diabetes Self-Management tool documents aspects of the participant’s disease (blood pressure, blood glucose, A1C) and health goals. This was trialed in a small group of SASH participants that have established diagnoses of type II diabetes. Weekly one-on-one check-ins were conducted among all the participants. At the end of the trial, all materials were placed in an electronic repository, accessible by all Wellness Nurses and education was provided regarding how the tools can best be utilized.

Results: Outcomes were assessed by questionnaires administered to participants who trialed the Diabetes Self-Management tools. Questions pertained to satisfaction, ease of use, and perceived helpfulness. Survey results revealed that most participants did not feel a need for a formal Diabetes Self-Management program or education and that their diabetes was already adequately managed. Survey results from the SASH Wellness Nurses revealed a need for a set of Diabetes education and management materials which could be used to help coach and educate newly diagnosed diabetics.

Conclusion: SASH participants who agreed to take part in the Diabetes Management Program had pre-existing methods for managing their diabetes and did not feel the need to incorporate the Self-Management Tool in their daily routine. Tools designed for this project were placed in an on-line repository for SASH wellness nurses to use for future educational purposes of newly diagnosed diabetics.

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