Health Assessment Resources – Type 2 Diabetes

When beginning a DRIVE program, it is critical to first identify the issue(s) that need to be improved upon, as well as any significant gaps in performance.

In order to do so, data from different areas of a practice or health system are to be collected and assessed to pinpoint the quality improvement (QI) activities that need to be focused on.

To facilitate this objective, the DRIVE resources highlighted in this phase can help structure the right focus, while shaping and understanding baseline needs. This, in turn, will help inform the pathway to take for the DRIVE program.

Three Main Resource Categories

Below are the 3 main resource categories in the DRIVE program that provide different tools and methods to help identify gaps, needs, and/or issues to best target improvement efforts:

Resource CategoryExamples of Health Areas Addressed
Community Health
  • Find health disparities related to type 2 diabetes in your region
  • Understand the epidemiology of type 2 diabetes (eg, incidence rates, prevalence, death rates, hospitalization rates, comorbidities, etc.), its prevention, and treatment
Health System and Clinic
  • Identify patients by race with A1c greater than 9 in the electronic health record
  • Characterize type 2 diabetes performance measures in this population, including foot exams and eye exams
Practice Organization and Workflow
  • Examine workflow in the practice and complete the practice assessment survey

Understanding the baseline population health needs can come from community resources, the own health system (eg, EHR data) and by examining what is happening in a practice (eg, by filling out a practice assessment survey and workflow analysis worksheets).

Tips for Collecting Data

During the Assess and Understand phase, it is crucial to collect a variety of data that is pertinent for this QI activity. Here are some recommendations on collecting data effectively:

A planning meeting with all participants can be used to develop a strategy for collecting and/or reviewing baseline data and health care gaps in a consistent way

Applying the “Assess and Understand” phase in-practice

Below are two examples showcasing how the tools and resources in this phase can begin to help address specific needs.

Example 1

A physician may want to better understand the impact of type 2 diabetes on her Black and Hispanic patients, especially during the COVID-19 pandemic.

The physician could explore the following resources and tools:

Refresh knowledge on type 2 diabetes standards of care, tools for prevention, and patient self-management

Access pertinent literature on the statistics and disparities in type 2 diabetes outcomes

Visit these geo maps to identify local, state, and national data on type 2 diabetes patients

The physician might now ponder about the different approaches and options for managing and treating her patients with type 2 diabetes

Example 2

A leader of a prominent predominantly Black church in Baltimore, MD recognizes there have been several hospitalizations from patients living with type 2 diabetes in their congregation. The church leader wants to understand the issues better in order to improve health conditions in the community. He/she can start by looking at the data on health outcomes from the Office of Minority Health (OMH): Diabetes in African Americans website. This could lay the groundwork to present a case to the local public health and/or health system, providing proof that interventions for lifestyle changes are needed.

Provider and Community Health Resources

Identify Local Health Disparities

Access big data analytics to help accelerate knowledge for a specific condition or therapy

Assess Community Health Needs

Assess the health needs of the local community

Measure public health in local region with NACCHO  Community Health Assessment and Improvement Planning

Better understand patients’ social determinants of health with the PRAPARE Protocol

Refresh knowledge on type 2 diabetes standards of care, tools for prevention, and patient self-management

Access pertinent literature on the statistics and disparities in type 2 diabetes outcomes

Visit geo maps to identify local, state, and national data on type 2 diabetes patients

Health System and Clinic Performance Resources

Uncover Type 2 Diabetes Measures at Health Systems and Clinics

The following illustrates different approaches for stakeholders to generate, assess, and utilize pertinent data about their QI performance.

  1. Health system, clinic, and/or provider level performance data to consider
    • How to obtain data on disparities in type 2 diabetes health outcomes and performance data, and which factors need to be considered when acquiring this data
  2. Data access from Electronic Health Records (EHRs), manual chart sampling, patient surveys, and practice assessments
  3. Common performance reports generated in clinic or health systems (if possible)
  4. Health outcome and performance assessment by demographic group or comorbidity
    • For example, communities of color are more likely to experience disparities in access to medications that results in nonadherence to treatment. Thus, it might be pertinent to focus on patient populations who are non-adherent to type 2 diabetes medications
  5. Data and insights identify areas for improvement and set the baseline for improvement projects and measurement
    • Once the type of data to be utilized is established for a particular population, then the gap on which area to focus can be revealed
  6. Regular reporting set up to track improvement moving forward

Please note that a performance rate is only as good as the data entered into system. Consequently, make sure to carefully review sources and processes for assessing QI projects that can be activated separately and on their own.

If you have used a DRIVE Toolkit to improve health outcomes or need additional assistance, please contact us by filling out the form below.