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 Category | Examples of Health Areas Addressed |
| Community Health |
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| Health System and Clinic |
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| Practice Organization and Workflow |
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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:
- Diabetes Practice Assessment: Center for Sustainable Health Care Quality and Equity clinical practice assessment
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
Example 1A 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
American Diabetes Association (ADA): Standards of Medical Care in Diabetes – 2021
Access pertinent literature on the statistics and disparities in type 2 diabetes outcomes
Centers for Disease Control (CDC): National Diabetes Statistics Report, 2020
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
National Minority Quality Forum: Patient Advocacy Learning Communities
Assess Community Health Needs
Assess the health needs of the local community
CDC’s Community Health Assessments and Health Improvement Planning
Measure public health in local region with NACCHO Community Health Assessment and Improvement Planning
National Association of County and City Health Officials (NACCHO)
Better understand patients’ social determinants of health with the PRAPARE Protocol
PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences
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.
- 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
- Data access from Electronic Health Records (EHRs), manual chart sampling, patient surveys, and practice assessments
- Common performance reports generated in clinic or health systems (if possible)
- 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
- 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
- Regular reporting set up to track improvement moving forward
