Utilize existing information systems identify patients at high risk for pre-diabetes and integrate these systems with PECS.

Cycle 1

Cycle 2

Cycle 3

Cycle 4

Cycle 5

Identify patients at risk during provider/patient encounters by integrating a screening protocol into the flow sheet

 Cycle 1

Cycle 2

Education for providers and other staff regarding identification of “at risk” population

Community outreach questionnaire will be used to identify populations at risk pre-diabetes.

Integrate a Referral process to Laboratory for 2 hour oGTT

Cycle 1

Laboratory Referral Form for 2 Hour OGTT

Integrate PECS to track pre-diabetics and evaluate established measures for monthly reporting

Develop algorithm to determine need for  transfer to diabetes registry

Linkages with the state Diabetes Control Programs (DCP to develop/identify resources to the IGT population in lifestyle interventions (i.e. obtaining pedometers)

Create a diabetes prevention website page

Planned visit to include dietitian/nutritionist

Create guidelines for patients who are at high risk for pre-diabetes.

Patients will set self-management goals around the lifestyle interventions, which will be supported through community linkages

Gain support of senior leadership regarding the translation of the DPP into primary care practice

Cycle 1

Cycle 2

Develop culturally sensitive curriculum covering diet, exercise and behavior modification

Nutrition Education:

Provided through the Center's Adult and Community Nutrition Program.

Physical Activity:

1. Exercise  classes being held twice a week at the Boys and Girls Club.

2. Participants are holding walking groups more often through a group leader volunteer.

Review reimbursement policies