Scribd Logo
Upload

Welcome to Scribd!

  • 32 views

    Diabetes Risk Stratification Assessment Tool

    Uploaded by

    Nyan Gyishin
    This document provides a scoring system to stratify diabetes patients into risk levels - red, yellow, and green zones - based on factors like A1C, blood pressure, statin use, tobacco use, and depression screening. The red zone indicates maximum support is needed, yellow indicates moderate support, and green indicates minimal support. It then provides checklists of care recommendations tailored to each risk level, including assessing readiness to change, addressing barriers, follow-up strategies, education, goal-setting, and referrals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Diabetes Risk Stratification Assessment Tool

    Uploaded by

    Nyan Gyishin
    32 views1 page
    This document provides a scoring system to stratify diabetes patients into risk levels - red, yellow, and green zones - based on factors like A1C, blood pressure, statin use, tobacco use, and depression screening. The red zone indicates maximum support is needed, yellow indicates moderate support, and green indicates minimal support. It then provides checklists of care recommendations tailored to each risk level, including assessing readiness to change, addressing barriers, follow-up strategies, education, goal-setting, and referrals.

    Original Title

    Diabetes_Risk_Stratification_Assessment_Tool

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides a scoring system to stratify diabetes patients into risk levels - red, yellow, and green zones - based on factors like A1C, blood pressure, statin use, tobacco use, and depression screening. The red zone indicates maximum support is needed, yellow indicates moderate support, and green indicates minimal support. It then provides checklists of care recommendations tailored to each risk level, including assessing readiness to change, addressing barriers, follow-up strategies, education, goal-setting, and referrals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views1 page

    Diabetes Risk Stratification Assessment Tool

    Uploaded by

    Nyan Gyishin
    This document provides a scoring system to stratify diabetes patients into risk levels - red, yellow, and green zones - based on factors like A1C, blood pressure, statin use, tobacco use, and depression screening. The red zone indicates maximum support is needed, yellow indicates moderate support, and green indicates minimal support. It then provides checklists of care recommendations tailored to each risk level, including assessing readiness to change, addressing barriers, follow-up strategies, education, goal-setting, and referrals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Diabetes Risk Stratification Assessment

    RISK STRATIFICATION SCORING (Circle Patient Score)


    1. Patient A1C* Points 2. Blood Pressure Points
    >9.0% or Unknown 7 Unknown 3
    8.5% to 9% 6 SBP>160 or DBP>95 3
    8.0% to 8.4% 5 SBP 140 to 160 or DBP 90 to 95 2
    7.5% to 7.9% 4 SBP 130 to 139 or DBP 80 to 89 1
    7.0% to 7.4% 2 SBP<130 or DBP<80 0
    <7% 0
    3. Statin Use/LDL Points 4. Tobacco Status Points
    Lipids not available 2 Unknown 1
    Statin absent and LDL>100 or non HDL>130 2 Current every day smoker 1
    Statin present and LDL>100 or non-HDL>130 1 Current some day smoker 1
    Statin absent and LDL<100 1 Tobacco Positive (pipes, smokeless, etc.) 1
    Statin present and LDL<100 0 Never Smoker or Recently Quit 0
    5. PHQ-9 Score Points Scoring Points
    Unknown 3 1. Patient A1C
    > 14 (moderately severe to severe depression) 3 2. Blood Pressure
    10 to 14 (moderate depression) 2 3. Statin Use/LDL
    5 to 9 (mild depression) 1 4. Tobacco Status
    *Patient A1C: Points are based on the widely recognized goal of 7%. In some 5. PHQ-9 Score
    instances, this goal may not be warranted or safe in which case the goal would be
    set at 8% and all data sets would be adjusted upward (+1% to each parameter). TOTAL

    RED ZONE YELLOW ZONE GREEN ZONE


    Maximum support needed. Moderate support needed. Minimal support needed.
    Overall Stratification Score > 6 Overall Stratification Score 3 to 6 Overall Stratification Score < 3

    YES NO N/A RED ZONE (Maximum Support Needed)


    Did you address the patient’s readiness to change? If so, what stage is the patient? __________________________
    Did you address any known community barriers? If so, what are they? __________________________
    Did you enlist a specific visit or phone call follow-up strategy (recommended someone call patient 2 weeks before and after all
    encounters)? If so, who called the patient? ___________________________________
    Did you enlist a specific “no show” strategy (recommended someone call patient same day if no show)? If so, who called the
    patient? ___________________________________
    Did you enlist a specific follow-up strategy for ED/Admin alerts (recommended someone contact the patient within 24 hours to
    schedule an appointment and follow-up within 72 hours)? If so, who contacted the patient?
    ___________________________________
    Did you assist the patient with coordination of other care services during their visit? If so, what did you coordinate?
    ___________________________________
    Did you address the need for ongoing education and self-management support?
    Did you make a referral to a CDE? If so, to whom? ___________________________________
    Did you schedule a class? If so, when/where? ___________________________________
    Did you set self-management goals with the patient? If so, what are they? ___________________________________
    Did you address the need for increased frequency of visits to the MD? CDE? Other?
    YES NO N/A YELLOW ZONE (Moderate Support Needed)
    Did you consider assessing the patient’s readiness to change? If so, what stage is the patient? __________________________
    Did you consider any known community barriers? If so, what are they? __________________________
    Did you enlist a specific visit or phone-call follow-up strategy? If so, who contacted the patient? ___________________________
    Did you consider the need for education and self-management support?
    Did you recommend an encounter with a dietician? If so, who? ___________________________________
    Did you schedule a class? If so, when/where? ___________________________________
    Did you set self-management goals with the patient? If so, what are they? ___________________________________
    YES NO N/A GREEN ZONE (Minimal Support Needed)
    Do you anticipate any future problems with the patient? If so, what are they? ___________________________________
    Did you offer education and self-management support?
    Did you offer a class for new or recent onset patients? If so, when/where? ___________________________________
    Did you offer an encounter with a dietician? If so, who? ___________________________________
    Did you offer to set self-management goals with the patient? If so, what are they? ______________________________

    PLEASE NOTE: Care recommendations detailed below are intended to supplement and/or extend the care guidelines that already exist for all diabetes patients and in no way reflect a comprehensive
    care management plan. ACKNOWLEDGMENT: University of North Carolina Chapel Hill Center for Excellence in Chronic Illness Care

    You might also like