Care Process Model
FE B RUA RY
2014
Diabetes Prevention Program
This care process model (CPM) was created by the Diabetes Prevention and Management Work Group and the Primary Care
Clinical Program at Intermountain Healthcare (Intermountain). It summarizes current medical literature and, where clear evidence
is lacking, provides expert advice on diagnosing prediabetes and preventing diabetes. In addition, this CPM facilitates population
management of diabetes prevention by outlining a systematic process for sharing accountability between clinicians, dietitians,
patients, operational and clinic staff, and the Primary Care Clinical Program.
WHAT’S INSIDE?
Why Focus ON DIABETES PREVENTION?
• Prediabetes is common and underdiagnosed. In 2010, approximately 1
in 3 U.S. adults, an estimated 79 million people, had prediabetes. During
2005–2010, fewer than 14% of those with prediabetes were aware of their
condition, regardless of education level, income, insurance coverage, or
healthcare use.CDC
• Up to 1⁄3 of people with prediabetes will progress to diabetes in 3 to 5
years. This will increase their risk of cardiovascular disease, stroke, high
blood pressure, blindness, kidney and nerve disease, and amputation.ADA
Preventing diabetes will help prevent other serious chronic conditions.
• Progression to diabetes can be prevented. In a 10-year follow-up study
of the U.S. Diabetes Prevention Program (DPP), patients in the intensive
lifestyle intervention (ILI) arm of the trial had a 34% reduction in the rate
of conversion to type 2 diabetes.ADA,DPP1
• Diabetes prevention is cost effective. The 10-year follow-up study of the
DPP concluded that investment in lifestyle and metformin interventions for
diabetes prevention in high-risk adults is highly cost effective.DPP2 With the
same results (34% reduction in progression to diabetes), Intermountain would
realize a significant cost savings.
• Intermountain has systems in place to achieve the same results as the
DPP — or better. Intermountain’s ILI program (The Weigh to Health®)
aligns closely with the curriculum of the DPP ILI. More importantly,
Intermountain has the data collection and reporting, decision support, and
team coordination to identify and engage all patients with prediabetes in our
system, across all population groups.
Key features to support shared accountability
Diabetes prevention is the shared responsibility of clinicians, dietitians, operational and clinic
staff, the Primary Care Clinical Program, and patients. This CPM outlines a plan for shared
accountability in this process. It includes:
• A flow process outlining how each patient will be identified, engaged, educated, and
monitored. (See page 2.)
• A chart defining the roles and responsibilities of each member of the team, and how the
complex task of diabetes prevention is shared across a team. (See page 4.)
PATIENT ENGAGEMENT
FLOW PROCESS ALGORITHM. . . . . . . . . 2
Algorithm notes . . . . . . . . . . . . . . . . . . . . . 3
ROLES AND RESPONSIBILITIES. . . . . . . 4
ONGOING FOLLOW-UP
AND SUPPORT. . . . . . . . . . . . . . . . . . . . . . .
Usual care . . . . . . . . . . . . . . . . . . . . . . . . . .
Intensive lifestyle intervention . . . . . . . . .
Medical nutrition therapy . . . . . . . . . . . . .
5
5
5
5
RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . 6
Patient education . . . . . . . . . . . . . . . . . . . . 6
Provider resources. . . . . . . . . . . . . . . . . . . . 6
EVALUATION . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . 7
MEASUREMENT &
EVALUATION
Intermountain is making a deliberate effort
in CPM development to recommend and
report on measurable outcomes that can
be tied to process variations. These will
provide a learning feedback loop by which
process variations, outcomes results, and
new research findings can be used for
continuous improvement of the model.
See page 7 for a discussion of measurement
and evaluation and how they relate to
diabetes prevention.
Indicates an Intermountain measure
DIABETES PREVENTION PROGR AM
FEB RUA RY 2 014
ALGORITHM: PREDIABETES PATIENT ENGAGEMENT AND TREATMENT
Screen all patients age ≥ 45 years or with BMI
≥ 25 kg/m2 and one or more risk factors using
HbA1c and/or FPG; if tests are normal, repeat
testing at 3-year intervals. Risk factors includeADA2:
SCREEN patients
PRIMARY CARE CLINICAL PROGRAM (PCCP) IDENTIFIES
prediabetes patients and communicates to clinic via Excel file (a)
PHYSICIAN REVIEWS list and communicates updated list to CLINIC
CLINIC ADDS prediabetes to patient’s problem list as appropriate
and COMMUNICATES updated list back to PCCP
PHYSICIAN INVITES patient to attend
free prediabetes class and communicates objectives of the class (b)
PATIENT AGREES to
register for the class?
no
yes
•• Physical inactivity
•• 1st-degree relative
•• History of CVD
•• Hypertension ≥ 140/90
•• African American,
•• HDL < 35 mg/dL
with DM
American Indian,
Alaskan Native,
Latin American,
Asian American,
Pacific Islander
•• Women with GDM
or have delivered
a baby > 9 lbs
mm Hg or on therapy
and/or triglyceride
level > 250 mg/dL
•• A1c ≥ 5.7%, IGT or IFG
on previous tests
•• Other conditions
associated with
insulin resistance
•• PCOS
CONSIDER metformin therapy — in addition
to lifestyle intervention — for patient with
BMI ≥ 35 kg/m2, age < 60, or with prior
gestational diabetes (c)
CLINIC CONTACTS
patient to schedule
follow‑up visit in
3 to 6 months (e)
CLINIC PSR MESSAGE LOGS referral to region prediabetes message box
and MEDICAL ASSISTANT or PCP ORDERS “Prediabetes class” in cPOE
REGION CENTER SCHEDULES patient for prediabetes class
through Centricity Business
PATIENT ATTENDS 2-hour prediabetes class (d)
•• Completes forms at end of class
•• Self-identifies lifestyle goal and one of the next steps below
Usual care AND
®
The Weigh to Health
program
(see page 5)
®
The Weigh to Health
STAFF CONTACTS
patient, confirms insurance
coverage, and determines
start date
Usual care AND
Medical nutrition
therapy (MNT)
(see page 5)
Usual care only
(see page 5)
PATIENT SCHEDULES
appointment with dietitian
at end of class; confirms
insurance coverage
CLINIC CONTACTS
patient to schedule
follow‑up visit in
3 to 6 months (e)
CLINIC CONTINUES to monitor all patients’ HbA1c and FPG at least yearly
DIETITIAN COMMUNICATES
class attendance and next steps
•• SCANS completed forms into medical record:
–– Lifestyle and Health Risk Questionnaire
(CPM015b)
–– Readiness Worksheet (CPM015d)
–– Diabetes Prevention Program Next Steps
Selection Form (DB042)
•• MESSAGE LOGS primary care physician
(and, if selected, The Weigh to Health® staff)
with patient’s:
–– Date of class attendance
(or if scheduled patient did not show up)
–– Self-identified lifestyle goal
–– Selection of next step
•• VERIFIES that prediabetes appears on problem
list (even if patient did not show up)
Indicates an
Intermountain measure
2 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
FEB RUA RY 2 014
DIABETES PREVENTION PROGRAM
ALGORITHM NOTES
(a) Identification and criteria for diagnosis
(b) Physician invites patient to attend class
•• Diagnosis includes patients with HbA1c 5.7% to 6.4% or FPG 100 to 125
mg/dL in the previous 3 years.ADA
Invitation should be in person or by personal phone call from physician (or
care manager if care manager has an established relationship with patient).
•• PCCP Excel file includes all patients meeting diagnostic criteria who are
not already in the diabetes registry.
•• Introduce risk: For example, “We have a new program in place
to identify patients who may be at increased risk for diabetes.
Your lab results show that you may be at increased risk.”
Note: Prediabetes should not be viewed as a clinical entity in its own right,
but as a risk factor for diabetes and cardiovascular disease.ADA
•• Invite patient to class and communicate the class objectives:
For example, “I’m recommending that you attend a free, 2‑hour class. The
class will help you choose a program that can help you make a plan to
prevent diabetes. Diabetes prevention will help you prevent other chronic
conditions as well.”
Note: Even patients not on the prediabetes list can be invited to the class.
(c) Metformin therapy
•• The ADA currently recommends metformin only for those at highest risk of developing diabetes (age < 60, BMI > 35, or history of gestational diabetes).
Metformin is especially recommended for patients who demonstrate progression to diabetes (HbA1c ≥ 6%) despite lifestyle interventions.
•• Follow-up required. Patients treated with metformin should be monitored twice a year with FPG and HbA1c testing.ADA
•• For more information on metformin therapy, refer to the Intermountain CPM Adult Diabetes Mellitus.
Medication class — Biguanide
2013 AWP cost for
30‑day supply*
(MAC cost for generics)
Usual dosing
metformin
(Glucophage)
metformin ER
(Glucophage XR)
500 mg twice a day (once
a day to start) to 1000 mg
twice a day (max)
Most benefit obtained
between 1500–1700
mg/day
Generic: (Tier 1)
500 mg twice a day: $3
850 mg twice a day: $4
1000 mg twice a day: $4
Brand name: (Tier 3)
500 mg twice a day: $68
850 mg twice a day: $115
1000 mg twice a day: $139
Pros
May prevent weight gain.
Favorable lipid effects.
No hypoglycemia.
Maximum PG effect at 3–4 weeks.
Decreases insulin resistance.
Consensus first-line agent.
Generic: (Tier 1)
500 mg once a day: $2
750 mg once a day: $4
1000 mg (2 X 500 mg): $4
1500 mg (2 X 750 mg): $8
Brand name: (Tier 3)
500 mg once a day: $35
750 mg once a day: $52
500 mg to 1500 mg
once a day at dinner
Cons
GI distress (nausea/diarrhea).
B12 deficiency — suggest
periodic testing.
CHF patients should be stable.
Increased risk of acidosis:
•• STOP with acute illness,
dehydration, or IV
contrast dyes.
•• Do not use for patients
with chronic liver disease,
alcoholism, renal failure
(as suggested by serum
creatinine ≥ 1.5 in men or
≥ 1.4 in women), or decreased
creatinine clearance in
elderly (eGFR < 30).
* Tier: Tier 1 = $5 to $15 copay; Tier 2 = $30 to $45 copay; Tier 3 = $60 to $75 copay (based on typical SelectHealth 2013 benefit design; some benefit designs may differ).
(d) 2-hour prediabetes class
•• The 2-hour prediabetes class, Pre-diabetes 101 — What is it and what can I do •• Topic covered in the class include:
about it?, is taught by registered dietitians and offered at no cost to participants.
–– What is prediabetes — and what is diabetes?
•• The class transfers responsibility for prediabetes education, self‑management
–– Why is diabetes such a big concern?
training, and follow-up to registered dietitians.
–– What is your risk of getting diabetes?
•• To find out where and when this class is offered, visit the Diabetes Prevention
Program page.
–– What can you do to prevent diabetes?
–– What are you ready to do? (Patients will be encouraged to set one small
lifestyle goal.)
–– What’s your next step? (Patient will choose to continue with The Weigh
to Health® intensive lifestyle intervention (preferred), medical nutrition
therapy, or usual care.)
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
3
DIABETES PREVENTION PROGR AM
FEB RUA RY 2 014
ROLES AND RESPONSIBILITIES
 KEY PRINCIPLES
Diabetes prevention requires a coordination of roles to ensure a systematic process for:
Individual clinics may choose to arrange
their processes slightly differently.
• Team coordination and support
Any changes should be documented
and communicated so all staff members
remain clear on who is responsible for
each activity.
• Proactive identification of patients with suspected or confirmed prediabetes
• Patient education, engagement, and self-management training
• Documentation and reporting
• Patient visit and follow-up
Each staff member has an important role in establishing this process. The table below
recommends responsibilities for each staff member to ensure the program’s success.
TABLE 1: OVERVIEW OF ROLES AND RESPONSIBILITIES
Role
Responsibility
Operations director (OD),
Assistant operations director
(AOD), Regional nurse
coordinator (RNC)
•• Direct report: PC Clinic Manager
•• Determine operational process for classes in region
•• Advocate the need for prediabetes implementation in region
•• Communicate roll-out to clinic managers
Primary care clinic manager
•• Direct reports: Primary care
provider, PCP MA, PSR
•• Define owner/contact for each step of prediabetes process
•• Understand process and importance of implementation
•• Continue to support referral of patients with prediabetes to 2-hour introductory class
Primary care provider (PCP)
•• (Initially) review PCCP list of patients with prediabetes and determine which should receive prediabetes
diagnosis; give list to MA to add to prediabetes problem list
•• Follow guidelines for screening and diagnosing patients with prediabetes
•• Invite patient to attend 2-hour prediabetes class and communicate class goals
•• Help prepare patient for readiness to change
•• Continuously monitor patient’s improvement and routinely schedule follow-up appointments
Care manager
•• May invite patient to participate in Diabetes Prevention class if established a relationship with the patient
PCP’s medical assistant
(PCP MA)
•• Add prediabetes to patient’s problem list in HELP2
•• Order “Prediabetes Class” in cPOE
Patient services
representative (PSR)
•• Message log referral to diabetes center using prediabetes hot text
Diabetes clinic manager
•• Work with OD/AOD/RNC on implementation of prediabetes class
•• Arrange class schedule and schedule for dietitians to teach prediabetes class
•• Communicate with clinic managers, if necessary, to schedule rooms/availability for dietitians to teach in-clinic
•• Schedule rooms at diabetes clinic for 2-hour class
•• Direct reports: OD/AOD/RNC
•• Assign message log referral box to PSR for daily checking and scheduling of patients
4 Diabetes clinic PSR
•• Check prediabetes referral box daily
•• Call patients to schedule time to attend next class, or class in their area if applicable
•• Check patients in for classes, if applicable
•• Schedule patients with dietitian after the class, for patients who select MNT
Dietitian
•• Follow curriculum for teaching 2-hour prediabetes class
•• Educate patients about prediabetes using standardized slide set
•• Have patients fill out forms according to prediabetes flow process
•• Encourage selection of The Weigh to Health® intensive lifestyle intervention
•• Message log PCP with patient’s attendance (whether or not attended), lifestyle goal, and next step selection
•• Scan completed patient forms into medical record (this may be delegated to PSRs at some clinics)
•• Verify prediabetes is listed on patient’s problem list
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
FEB RUA RY 2 014
DIABETES PREVENTION PROGRAM
ONGOING FOLLOW-UP AND SUPPORT
ADA recommendations for usual care
KEY RECOMMENDATIONS
The ADA recommends the following ongoing support for all patients with prediabetes:
• All patients should participate in
usual care with primary care provider.
• Counsel all patients to increase physical activity. Most should aim for 30 minutes
• Encourage all patients to participate
of moderately intense exercise (such as a brisk walk) most days of the week, for a
minimum of 150 minutes (2.5 hours) total exercise per week.
in Intermountain’s intensive lifestyle
intervention, The Weigh to Health®.
• For overweight or obese patients, advise weight loss of 7% to 10% of body weight.
• For patients who are not able or
For a 250 pound person, this means a weight loss of 17 to 25 pounds.
willing to do an ILI, recommend
medical nutrition therapy.
• Consider metformin therapy for some patients, as outlined in box (c) on page 3.
• Follow up at least annually with HbA1c or FPG testing. For patients taking
metformin, follow up every 6 months.
• Screen and treat to reduce cardiovascular risk factors, including hypertension,
dyslipidemia, and tobacco use.
PATIENT HANDOUTS TO
INTRODUCE SUPPORT PROGRAMS
• Manage sleep and stress issues. Intermountain’s Lifestyle and Weight Management
These brochures will be available at the
2‑hour Prediabetes class. Both include
phone numbers of clinics where patients
can call to register.
CPM provides guidance in this area.
• Refer to an effective ongoing support program targeting lifestyle change. The two
support programs below target lifestyle change.
The Weigh to Health ® program — Intermountain’s intensive
lifestyle intervention (ILI)
The Weigh to Health program
®
The curriculum is the same at all
participating Intermountain Healthcare
facilities. These include:
Outcome studies of the Diabetes Prevention Program (DPP) showed that a 16-week
ILI reduced incidence of type 2 diabetes by 58% at 2 years.DPP1 The Weigh to Health ®
was redesigned in 2012 to meet the Affordable Care Act criteria for an ILI for weight
loss. The curriculum was also mapped to the ILI used in the DPP and shown to be in
very close alignment.
WHAT CAN
The Weigh to Health® program
DO FOR YOU?
The Weigh to Health® program can help you
feel better every day. You’ll learn how to make
changes in your life that will help you lose extra
weight. Those same changes will also help you:
• Have more energy
• Be more confident
• Reduce stress
• Sleep better
• Be more active
• Manage chronic health
• Group classes are taught by registered dietitians, with guest instructors such as
conditions
exercise specialists, behavior specialists, and chefs.
American Fork Hospital
Cassia Regional Medical Center
Intermountain Medical Center
LDS Hospital
LiVe Well Center Salt Lake City
LiVe Well Center St. George
Logan Regional Medical Center
McKay-Dee Hospital Center
Riverton Hospital
TOSH -The Orthopedic Specialty Hospital
Utah Valley Regional Medical Center
Valley View Medical Center
801-855-3461
208-677-6288
801-507-3253
801-507-3253
385-282-2700
435-251-3793
435-716-5310
801-387-7854
801-507-3253
801-507-3253
801-357-8143
435-868-5335
NUTRITION COUNSELING
Your insurance may also cover one-on-one nutrition
counseling with a registered dietitian for diet-related
conditions (separate from The Weigh to Health® program).
No referral is necessary. SelectHealth members are
eligible for five one-on-one outpatient visits per year at
no cost. Nutrition counseling is offered at all the facilities
listed above, as well as:
Alta View Hospital
Bear River Valley Hospital
Delta Community Medical Center
Fillmore Community Medical Center
Garfield Hospital
Heber Valley Medical Center
LiVe Well Center Park City
Sanpete Valley Hospital
Sevier Valley Hospital
801-507-3253
435-716-5310
435-864-5591
435-743-5591
435-676-1258
435-657-4311
435-658-7880
435-462-4620
435-893-0569
For more information visit
www.intermountainhealthcare.org/nutrition
• Patients attend 12 (or more) sessions over a 6-month period. Patients can enter the
© 2007 - 2013 Intermountain Healthcare and SelectHealth. All rights reserved.
This information is not a substitute for professional medical advice, nor should it be used
to diagnose or treat a health problem. Please consult your healthcare provider if you have
questions or concerns. Patient and Provider Publications 801-442-2963 HH012 – 10/13
program at any time, but are encouraged to take the orientation session early on.
The Weigh to
Health
®
LIFESTYLE & WEIGHT MANAGEMENT
PROGRAM
Nutrition Counseling
Nutrition counseling with a registered dietitian
can help you improve your health and feel
better — whether you’re already fairly healthy,
or you have complex medical conditions.
In nutrition counseling (also called Medical
Nutrition Therapy, or MNT) you’ll learn how to
improve your diet in order to lead a healthy life
or to achieve specific health goals. It includes:
• One-on-one counseling with a registered
dietitian. A registered dietitian is a nutrition
expert with a university degree and clinical
training in how diet can treat different
health conditions.
• A personalized eating plan and support.
Nutrition counseling is especially helpful for
diet-related conditions, such as:
– Cancer
– Celiac disease
– Diabetes or pre-diabetes
– Eating disorders
– Food allergies
– Gastrointestinal disorders
– Heart disease
– High blood pressure
– High cholesterol
– Weight management problems
Cost:
• SelectHealth members can have 5 visits a
year for diet-related issues, such as those
listed above. There’s no co-pay and nothing
out-of-pocket.
• Other insurance providers may cover nutrition
counseling. Call your provider to confirm.
Classes include:
–– An orientation class, focusing on basic principles of weight management.
–– Two 30-minute sessions with a dietitian trained in weight management.
–– At least nine 90-minute group classes. Patients choose classes based on personal
goals. Classes include physical activity (required), behavior change (required),
meal planning, emotional eating, label reading, body image, intuitive eating,
stress management, shopping on a budget, healthy cooking, and eating out.
• Some insurance providers, including Select Health, cover the entire cost of the
program for patients who complete it. Patients who do not complete the program
are charged for the sessions they attended.
Medical nutrition therapy (MNT)
• One-on-one nutrition counseling with a registered dietitian. Patients will learn
nutrition strategies to prevent diabetes and develop a personalized eating plan.
• Some insurance providers, including Select Health, cover up to 5 visits per year for
diet-related issues, including prediabetes. No referral is necessary.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
5
alth® program
ogram can help you
u’ll learn how to make
will help you lose extra
ges will also help you:
DIABETES PREVENTION PROGR AM
FEB RUA RY 2 014
RESOURCES
MATERIALS USED
IN THE 2-HOUR
PREDIABETES CLASS
Patient resources
These materials are also available to
patients online:
Call 801-442-3186 for ordering information.
Clinicians can order Intermountain patient education booklets and fact sheets for distribution to their
patients from Intermountain’s Online Library and Print Store, iprintstore.org.
LiVe Well
LiVe Well
FAC T SH EE T FO R PATI ENT S A N D FA M I LI ES
FAC T SH EE T FO R PATI ENT S A N D FA M I LI ES
Live Well, Move More
Live Well, Snack Wisely
Feel a little guilty when you reach for a snack? Don’t. Eating between your regular meals can be a healthy
part of your diet. If you plan for snacks the way you plan for other meals, you can have good choices ready
to go when hunger strikes. So go ahead and have a snack. Just be smart about it.
You can’t be healthy without being active. Research shows that no matter what your weight, regular physical
activity is one of the greatest predictors of health.
LiVe Well
Why is physical activity so important?
LiVe Well
How do I get started?
FAC T SH EE T FO R PATI ENT S A N D FA M I LI ES
Regular physical activity can help you feel better and be
Start with this idea: no physical activity is bad, some is
healthier both now and in the future. In fact, it can do to
good, and more is better. Wherever you are right now is
more improve your health than just about anything else.
a great place to start. From there, it can be as easy as 1-2-3.
Why?
1 Move more. Set aside some time every day when you
• It protects your health and helps you live longer.
can get your heart rate up a little. The goal is to build
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up to 150 minutes or more a week — or 30 minutes
overweight, using tobacco, or having high blood
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ready
to add in a few more.
Physical activity gives you more energy, relieves anxiety
your
life?
the biggest difference
in
• Maintain a healthy weight — or lose weight. again. Make small changes you can gradually build into
FAC T SH EE T FO R PATI ENT S
Snacks can work
in your favor
FACT SHEET FOR PATIENTS AND FAMILIES
Live Well, Sleep Well
Glucose comes from the food you eat, and is the body’s
main source of fuel. Your high blood glucose is a sign
that your body is having trouble getting energy from
your food. Instead of moving easily into your cells where
it can be burned for energy, glucose is building up in
your bloodstream.
Pre-diabetes 101: What is it
and what can I do about it?
(slide presentation)
What are the symptoms?
getting to bed on time. The recommendations below can help you get the
LiVe Well
Plan ahead to make a good choice be
an easy choiceStick to a schedule throughout the day
What are the risks?
How fast and how far do I need to go?
Your high blood glucose puts you at increased risk
for serious health problems, including the following:
If you’re not exercising at all, then start with walking 10
minutes a day. After a week or two, try increasing to 20
minutes a day. Keep building up a little every week. Aim
for the targets below for the greatest benefits.
There’s very little risk of injury from walking, but you still
need to consider a few things.
• How long: If you’re walking for general health, build
up to 150 minutes per week — or about 30 minutes
on most days. If you’re trying to lose weight, aim for
250 to 300 minutes per week — or 60 minutes on
most days. If you can’t get it all in at once, break it up
into as little as 10 minutes at a time.
• Get an okay from your doctor if you’ve had heart
trouble, chest pain, high blood pressure, dizziness, or if
you’re over 65 and haven’t been getting regular exercise.
• Developing diabetes. Many people with
pre-diabetes go on to develop diabetes. Diabetes
is a lifelong disease that can cause problems
throughout your body.
Most people with pre-diabetes have no symptoms and
don’t feel sick. The condition is discovered through
testing that measures blood glucose levels.
• Having a heart attack, stroke, or other
cardiovascular problem. Compared to a person
with normal blood glucose levels, you have a 50%
greater chance of heart attack or stroke.
If pre-diabetes progresses to diabetes, a person may
have symptoms of high blood glucose such as unusual
thirst and hunger, frequent urination, weakness, and
blurry vision.
Fortunately, there’s a lot you can do to lower your blood
glucose — and lower your health risks at the same time.
The back page of this handout explains how you can act
now to protect your health.
• How fast: Walk at a somewhat vigorous pace — so you
breathe a little harder than normal. If can still talk in
complete sentences, you’re about right. If you can sing
a song, try picking up the pace a little. The benefits
come from a brisk walk, not a stroll.
To build up, increase just one thing at a time: go one
more day per week, add few more minutes per day, or
walk a little faster. Do what works for you.
1
Date:
Meal
if with family
What’s stopping you?
You can learn to manage stress and
reduce health problems
• Insomnia. Nearly half of adults report lying awake at
night because of stress.
The good news is that you can learn to manage stress.
Learning to manage stress can help you stay healthier and
live better. Page 2 of this handout has ideas for building
your own stress management “tool kit.”
• Weakened immune system. People with chronic stress
take longer to recover from other illnesses.
1
LiVe Well Action Plan
Once you’ve chosen a goal, the most important next step is to make a detailed plan
for reaching it. Take your time and think carefully about your plan.
Example: 20 minutes of exercise at least
4 times a week. Do this for 3 weeks.
LiVe Well Readiness Worksheet
What will you do to meet your goal?
• What will your milestones be?Name
•
What are you ready to do?
How will you track and report your progress?
Use this worksheet to help you choose a healthy lifestyle goal that you’re ready to work on.
LiVell
LiVe Well Lifestyle and Health Risk Questionnaire
We
A
Person or team
doctor with theBgood news and I’ll make
a new goal with more minutes.
D
Support: My co-worker will remind me
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SB6
Which concern
are you most ready,
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Your Name:
Age: on NOW?
Sex:
SB8
I walked.
On the ruler, write the letter of each concern above a number
to shownotes:
how ready you
feel (inches):
to work on it right now.Weight (lbs):
Height
Provider
What might get in the way?
• In what situations will this be most
difficult for you?
Waist circumference (inches):
Date:
BMI:
SB5
Neck circumference (inches):
Example:
• What can you do in these situations?
How could you overcome
this?
Not ready
Unsure
Ready
P h y s i c a l A cI tmight
i v inot
t yfeel like walking when I’m
discouraged. When this happens, I’ll
Circle the concern you
farthest
to the
invitemarked
a co-worker
to go with
me. right.
Choose
work
onbethis
concern.
On average, how
manytodays
per
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notweek
abledotoyou
walkexercise
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if I
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have a meeting during that time. When
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HELP2, PAVS
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N A do
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BE
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RS
SB7
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C
Provider notes:
What will you do when you get off track? At what intensity (how hard) do you usually exercise?
 light (casual walk)  moderate
What specific behaviors or actions would help you with this concern?
(brisk walk)  vigorous (jog/run)
Talk
youron?
healthcare providersExample:
for ideas about what’s proven to help most.
Most people get off track now and then. What will you do
to with
get back
What types of physical activity do you do?HELP2 List:
If I miss a few days I’ll commit to
starting ___________________________________
again the next Monday.
___________________________________
How often do you do muscle strengthening
activities or exercises?
day/week:
___________________________________ minutes per day:
On
scale of 1-10, where 1 isUnsure
low and 10 is high, how ready,
willing,
Nota ready
Ready
and able are you to to improve your activity habits and stick to it?
I’m also tracking
q calories q
q
q
Lunch
q
q
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Hours sitting (aim low)
at work/school
outside work/school
q
q
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q Activity:
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q Minutes:
Intensity: q Light
q Moderate q Vigorous
Fruits
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if with family
q Moderate q Vigorous
q
q
Vegetables
q
q
Breakfast
Date:
Activity
q Activity:
(aim high)
q Minutes:
Intensity: q Light
q
q
Hours sitting (aim low)
at work/school
outside work/school
6-Week Habit Tracker
Sleep Number of hours I slept last night:
(circle one) S M T W T F S
Food item (portion size)
I’m also tracking
q calories q
Vegetables
q
q
Breakfast
q
q
Lunch
q
q
Snacks
q
q
Activity
q Activity:
(aim high)
q Minutes:
Intensity: q Light
q Moderate q Vigorous
Fruits
Dinner
q
q
Hours sitting (aim low)
at work/school
outside work/school
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH016- 05/13
More health information is available at intermountainhealthcare.org/wellness.
1
make wise food choices
manage your weight
enjoy your life every day1
Lifestyle materials
• Pre-diabetes: Act
An array of fact sheets and trackers to support lifestyle change, including:
• Starting a Walking Program
• Live Well, Sleep Well
• Live Well, Eat Well
• Live Well, Snack Wisely
• Live Well, Move More
• 1-Week Habit Tracker
• Live Well, Stress Less
• 6-Week Habit Tracker
A
minutes per day:
What else could help?
How many “screen-time” hours do you have each day: TV, video
Which behavior
or action are you most ready, willing, and able to do screen-time
NOW? hours per day:
games, sitting at the computer (not counting work and school)?HELP2
the ruler again.
Example:
This might include websites, trackers, more information, a partner to do this with, Consider
total sitting hours per day:
How many total hours sitting
you
eacha fitness
day (including at
I want todo
find
outhave
if there’s
or community groups.
program at my work.
work and school)?
Set your goal around the behavior or action you’re most ready to do.
q
q
Sleep Number of hours I slept last night:
(circle one) S M T W T F S
Example:
B
days per week:
HELP2, PAVS
___________________________________
q
q
Fruits
q
q
Snacks
Fact sheet
Now to Protect
Your Health
Example:
Walk around my office building for 20
minutes at lunchtime. Each week I walk
4 times it is a milestone.
• What is the specific action for your goal?
• How and when will you do this?
Example:
• How will you keep track?
Tracking: Every time I go I’ll put a check
• Who will you report to and how often?
mark on the calendar at my desk.
N A R R O W Reward
Y O U and
R Creport:
O N Each
CER
NS
• How will you reward yourself?
milestone
buy new music to listen to while
• Who will support you? This might include healthcare providers, familyWhat
members,
are your I’ll
biggest
health concerns?
walking. After 3 weeks, I’ll email my
friends, or group leaders.
Vegetables
q
q
Dinner
be physically active
Write your goal here:
I’m also tracking
q calories q
Lunch
Everyone responds to stress in their own way. It’s
• Protect your sleep
alwaysofsleep
in yourIfbedroom,
out—
a flood
hormones.
these hormones remain
(Never drink alcohol
while taking
sleeping
pills oryour own signs of stress.
important
to learn
to recognize
keep your bedroom dark and quiet, and avoid large
other medications.)
activated over time, they can cause health problems
Acute stress is easy to recognize. Some people start to
meals and alcohol before you sleep.
such as:
anything
in the
day.at someone. Chronic
• Don’t drink too much
sweat,ofclench
theirlate
teeth,
or yell
• If you take naps during your shift, sleep between
If you have to wake
up to
toilettoyou
may have
stress
canuse
bethe
harder
recognize.
Some people get used to
20 and 30 minutes
and blood
allow yourself
timeStress
for increases blood pressure,
pressure.
• High
drowsiness to wear
off. in turn increases risk of heart disease. trouble falling back
theasleep.
signs and don’t notice them anymore. People with
which
1
chronic stress often describe it as a feeling of being
• Obesity. When you’re stressed, you may be eating more
overwhelmed or out of control. It can lead them to feel
comfort foods to help you cope. Stress hormones can
tired all the time, irritable, or unable to concentrate.
also increase abdominal fat.
• Anxiety and depression. Stress can cause feelings
of despair.
Sleep Number of hours I slept last night:
(circle one) S M T W T F S
Food item (portion size)
Breakfast
Date:
see what worksWhen
best for
you.body
Everyone
is different.
your
perceives
stress, it responds by• sending
Don’t drink alcohol within 6 hours of going to bed.
• Walk with a friend when you can, and carry a cell
phone, just in case you have an unexpected problem.
Weight. If you need to lose
weight, take it slowly. One or two
pounds a week is a good goal. Weigh
yourself once a week.
My weight today:
My goal this week:
• Keep track of what’s important to you. If you want to lose weight, you may want to track calories. Or, you might track other nutrients
such as carbs, fiber, or salt. And don’t forget about sleep. You might be surprised at how your sleep can affect your other health habits.
• Be honest. You don’t need to impress anyone. You just need an accurate account of your daily choices.
• Be complete. Write down everything that goes in your mouth — especially when you don’t want to. Include portion sizes.
• Revisit your goals. Remember where you’re headed, and keep at it. Day by day, you CAN improve your habits — and your health.
Live Well, Stress Less
• Drink water before your walk, especially if it’s hot out.
During the summer, try to walk during the cooler
1
parts of the day.
Activity. Work up to at least
150 minutes of aerobic activity
a week — or 250 to 300 minutes if you
want to lose weight or maintain weight
loss. Sit less and move more throughout
the day.
My goal this week:
Tracking Tips
important nutrients that you need. A great
has both: stress andPlan
snack about
days. it.
Think
yousnack
understand
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that the
cansame
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• If you have trouble
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help you
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as really
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• High-fiber carbohydrates,
the day. Ifsuch
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and do
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when
them.
weight,ready
and your
riskyou
for need
chronic
disease.
fruits, and vegetables
sleepis
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but just aren’t
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What
stress?
This might be your desk, purse, bag, car, or fridge.
products,
nuts,
andcan
seeds
• Protein, such as dairy
sleeping
enough,
naps
be helpful.
Stress is your body’s way of responding physically and
Try to avoid snacks•that
are high
in fat, especially
Create
a bedtime
routinesaturated
you can go through for
emotionally to a challenging situation. Sometimes
stresswhat you eat and drink
Watch
or trans fat. They addabout
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calories
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youtoup.
This is NOT snacking
wisely:
minutes
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is positive — it can help you respond with more focus and
late in the
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include quiet activities such as reading for a few• What: Having chips,
to an emergency, for example. More often,candy,
stress sweetened drinks, or
2. How much? About
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other foods withWhat
a lot of
salt, fat,
or sugar
minutes,
tocalories
quiet music, or taking a bath.
youadded
consume
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afternoon and evening can
can cause you to feel out of control.
• How much: Eating
out
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bag or container
Even healthy snacks
have calories
cause
weight phone, electronic
affect
your
sleep.
screen and
timecan
(TV,
computer,
• Avoid
and not really knowing
a how much you just ate
There
different
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gain if you eat too much.
people,
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for at
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bed. Acute stress•is Don’t
drink caffeine (as in coffee or soda) within
• When:
Grazing
should be about 100 to 200 calories —
just enough
to situation, such
reaction
to a brief
as a traffic
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an all day, or eating when
6 hours
of gong
to bed.yourself
Caffeine is a stimulant and
you’re bored, stressed,
or want
to reward
keep you going until your next meal. argument.
If you’re really
Chronic stress comes from situations that don’t
can
keep
• Where: Snacking in
front
ofyou
the awake.
TV, computer, or
active, you might need
up to 300
calories.
haveshift
a quick
resolution. These might
include
caring for
A note
about
workers
any place
that distracts
youa from what you’re eating
1 other tobacco
• Don’t use nicotine (as in cigarettes and
disabled
family
member,
unemployment,
or the death of a
If you work irregular
shifts —
nights,
evenings,
etc. —
products) close to bedtime or during the night.
try these tactics toloved
help you
enough
sleep:
one.get
Chronic
stress
can also develop over time if
Nicotine is also a stimulant.
everyday
are ignored
or poorly managed.
• Schedule at least
7 hoursstressors
in bed, even
if you don’t
• Eat a light snack before bed so you don’t go to bed
sleep the entire time.
hungry. But don’tAm
eat a Ilarge
meal just before bed.
stressed?
How does
stress
affect
• Try sleeping at different
times after
your shifts
to my health?
What about safety?
If you’re having trouble getting started, think about the
reasons. Do you feel like you don’t have the time? Or a
good place to go? Or a friend to join you? Or someone to
watch your children? Do you have a health concern?
Whatever it is, write it down. Then start making a plan
to overcome it. Ask for help or support where you need it.
I’ll end up getting
a candyyou
bar from
sleep
need.
the machine.
You know you’re going
to getahungry
F A C Tmeals
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O Rday
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ENTS AND FAMILIES
Keeping
regularbetween
schedule
throughout
sometimes. If you plan
it, it’ll
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know
when easier
it’s time
to sleep.
3. WHEN and WHERE: A regular time and
good choices. If you don’t, you’ll be more likely to reach
place, if possible
• Try to go to bed and wake up at the same time
for convenient choices like candy, chips, and soda. Here’s
each day — even on weekends and days off work.
The best time to have a snack is when you’re physically
what to plan for:
hungry.
well. For many people, this is about every 2½ to 3
• Resist the urge to sleep in, even if you didn’t sleep
1. What: Healthy• foods
you need more of
hours. Snacking more often — or grazing all day —
Keep a regular schedule for meals, medications,
canbut
be a sign that you’re eating out of habit, out of
Choose foods that digest
slowly and Exercise
will keepatyou
and activities.
thefrom
same time each day,
boredom,
for have
emotional
getting hungry again
rightexercise
away —
and
thatcan’t
have
You
entirely
avoidto stress,
butoryou
morereasons.
control over it than you may think. This fact sheet will help
don’t
hard
within
3 hours
of going
bed.
and depression, and makes you sharper and more creative.
your life — and then stick with them for a lifetime.
Exercise is vital, but it’s also important to move more
• Feel better. Walking reduces stress and depression,
throughout the day, even if you sit for your job.
1 habits. You
This handout has lots of ideas for new
increases energy, improves sleep, and improves mood.
✓anext
Mark
aq
toperson, but I didn’t
don’t need to do them
all atthought
once! of
“I’d always
myself
as
healthy
These benefits won’t come all at once, though. This isone or two healthy
changes
you’re
ready
exercise,
and I didn’t
have
a lotto
of make
energy. I started walking
about building a lifelong habit that will pay off in the
just 10 minutes
at lunchtime.
It felt good,
now. When they become
routine,
you’ll be ready
to so I kept building
long run.
up — and up. Now I’m feeling healthy!”
add in another one.
More than 50 million U.S. adults have pre-diabetes.
All of them can do something about it.
Blood testing — such
as with a fasting plasma
glucose (FPG) test or
HbA1c test — can reveal
whether your blood
glucose is high and if it
means pre-diabetes
or diabetes.
Nutrition. Eat more vegetables,
fruits, and other high-fiber foods.
Watch your portions, and cut back on
sweets. Give yourself a  when you eat
with your family.
My daily goal:
My goal this week:
good choice
ready disease, and weight
• Manage your weight
—isbyimportant.
preventing you
Sleep
Notfrom
getting enough of it can increase your risk of depression,
chronic
to go. If I don’t,
getting too hungry
and For
overeating
your next
meal to sleep and staying asleep is difficult. Others
gain.
some at
people,
getting
fall asleep easily, but just aren’t
Starting a Walking Program
What is pre-diabetes?
If you have pre-diabetes, you have more sugar (glucose)
in your blood than normal — but not so much that you
can be diagnosed with diabetes.
LiVe Well 1-Week Habit Tracker
For me, smart
snacking starts at
the grocery store.
I try to plan ahead
and buy the foods
I like. Then when
hunger strikes at
3:00 I’ll have a
• Get better nutrition — by giving you more chances to
get in your fruits, vegetables, and other healthy choices
• Keep up your physical and mental energy between
meals — by keeping your blood sugar levels balanced
LiVe Well
Pre-diabetes: Act Now to Protect Your Health
AND FAMILIES
If you do it wisely, snacking every few hours can help you:
Live Well, Eat Well
(1-10):
Nutrition
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015e - 05/13
S Edays
T Ya O
U Rdo you
G OeatA aLhealthy breakfast?HELP2
On average, how many
week
On average, how many 12-ounce servings of sweetened drinks
My goal:do you have each day? HELP2
*50054*
average,
many servings
of fruits
vegetables
do yougoal.
eat
NowOnmake
anhow
Action
Plan to
helpand
you
reach your
HELP2
each day?
On average, how many meals per week do you eat with your family?HELP2
Cr Pln50054
© 2013 Intermountain Healthcare. All rights reserved. Patient
and Provider
801-442-2963
CPM015d
- 10/13 do
On average,
howPublications
many servings
of low-fat
dairy
you have each day?
On average, how many drinks of alcohol do you have each day?HELP2
(1 drink = 12-ounce beer, 5-ounce wine, 1.5-ounce liquor)
How often do you eat while doing other things like watching TV?
servings per day:
servings per week:
total servings per day:
(fruits:
/day; veggies:
servings per day:
drinks per day:
drinks per week:
 rarely  occasionally  often
 no
On a scale of 1-10, where 1 is low and 10 is high, how ready, willing, and
able are you to improve your nutrition habits and stick to it?
(1-10):
Pat Qst 50113
/day)
meals per week:
Do you ever eat in secret?
*50113*
Provider notes:
days per week:
 yes
1
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015b - 05/13
1
Behavior change
materials:
• Live Well Lifestyle and
Provider resources
To find this CPM and its reference list, clinicians can go to intermountain.net/clinicalprograms
and select Diabetes Prevention Program from the topic list on the left side of the screen.
Health Risk Questionnaire
• Live Well Readiness
Worksheet
• Live Well Action Plan
The Weigh to Health program
®
The curriculum is the same at all
participating Intermountain Healthcare
facilities. These include:
American Fork Hospital
Cassia Regional Medical Center
Intermountain Medical Center
LDS Hospital
LiVe Well Center Salt Lake City
LiVe Well Center St. George
Logan Regional Medical Center
McKay-Dee Hospital Center
Riverton Hospital
TOSH -The Orthopedic Specialty Hospital
Utah Valley Regional Medical Center
Valley View Medical Center
801-855-3461
208-677-6288
801-507-3253
801-507-3253
385-282-2700
435-251-3793
435-716-5310
801-387-7854
801-507-3253
801-507-3253
801-357-8143
435-868-5335
NUTRITION COUNSELING
Your insurance may also cover one-on-one nutrition
counseling with a registered dietitian for diet-related
conditions (separate from The Weigh to Health® program).
No referral is necessary. SelectHealth members are
eligible for five one-on-one outpatient visits per year at
no cost. Nutrition counseling is offered at all the facilities
listed above, as well as:
Alta View Hospital
Bear River Valley Hospital
Delta Community Medical Center
Fillmore Community Medical Center
Garfield Hospital
Heber Valley Medical Center
LiVe Well Center Park City
Sanpete Valley Hospital
Sevier Valley Hospital
801-507-3253
435-716-5310
435-864-5591
435-743-5591
435-676-1258
435-657-4311
435-658-7880
435-462-4620
435-893-0569
For more information visit
www.intermountainhealthcare.org/nutrition
© 2007 - 2013 Intermountain Healthcare and SelectHealth. All rights reserved.
This information is not a substitute for professional medical advice, nor should it be used
to diagnose or treat a health problem. Please consult your healthcare provider if you have
questions or concerns. Patient and Provider Publications 801-442-2963 HH012 – 10/13
The Weigh to
Health
Nutrition Counseling
®
LIFESTYLE & WEIGHT MANAGEMENT
PROGRAM
Nutrition counseling with a registered dietitian
can help you improve your health and feel
better — whether you’re already fairly healthy,
or you have complex medical conditions.
In nutrition counseling (also called Medical
Nutrition Therapy, or MNT) you’ll learn how to
improve your diet in order to lead a healthy life
or to achieve specific health goals. It includes:
• One-on-one counseling with a registered
dietitian. A registered dietitian is a nutrition
expert with a university degree and clinical
training in how diet can treat different
health conditions.
• A personalized eating plan and support.
Nutrition counseling is especially helpful for
diet-related conditions, such as:
– Cancer
– Celiac disease
– Diabetes or pre-diabetes
– Eating disorders
– Food allergies
– Gastrointestinal disorders
– Heart disease
– High blood pressure
– High cholesterol
– Weight management problems
Cost:
• SelectHealth members can have 5 visits a
year for diet-related issues, such as those
listed above. There’s no co-pay and nothing
out-of-pocket.
• Other insurance providers may cover nutrition
counseling. Call your provider to confirm.
Program descriptions:
• The Weight to Health
®
• Nutrition counseling
6 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
FEB RUA RY 2 014
DIABETES PREVENTION PROGRAM
EVALUATION
The goal of Intermountain’s Diabetes Prevention Program is to facilitate the
prevention of diabetes through a consistent clinical process, team-based care,
and rigorous evaluation. These processes are designed to increase patient
activation and provide support for lifestyle change and healthy living.
REFERENCES
The purpose of evaluation is to measure whether the program is effective in reaching
these goals, to determine which factors are contributing to the program’s success, and
to recommend program changes.
ADA American Diabetes
Association (ADA).
Standards of medical
care in diabetes — 2013.
Diabetes Care. 2013;36
(Suppl 1):S11-S61.
To enable this evaluation, we are measuring the following:
• Patient identification
–– Number of patients identified as having prediabetes
• Patient participation
–– Number of identified patients invited to participate in the 2-hour
Prediabetes class
–– Of those invited to the class, the number who attend
–– Of those who attend the class, number who participate in The Weigh to Health®
program or in Medical Nutrition Therapy — and the number of sessions
they attend
• Implementation
–– Number of providers and clinics enrolling patients in the 2-hour
Prediabetes class
–– Number of locations that offer the 2-hour Prediabetes class
• Clinical outcomes
–– Percent weight loss
–– Change in weight, HbA1c, fasting blood glucose, blood pressure, BMI, lipids
• Healthcare utilization
–– Number of “touches” with the system
–– Number of primary care vs. specialty care visits
–– Number of ambulatory care vs. acute care visits
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
The following are the primary
references used in this CPM:
ADA2 American Diabetes
Association (ADA).
Testing in Asymptomatic
Patients. Diabetes Care
January 2014;37(suppl 1)
s14-s80, Table 4.
CDC Centers for Disease Control
and Prevention (CDC).
Awareness of prediabetes
— United States, 2005–
2010. MMWR Morb Mortal
Wkly Rep. 2013;62(11):209212. http://www.cdc.gov/
mmwr/pdf/wk/mm6211.pdf.
DPP1 Diabetes Prevention
Program Research Group.
10-year follow-up of
diabetes incidence and
weight loss in the Diabetes
Prevention Program
Outcomes Study. Lancet.
2009;374(9702):16771686. doi: 10.1016/S01406736(09)61457-4.
DPP2 Diabetes Prevention Program
Research Group. The 10-year
cost-effectiveness of lifestyle
intervention or metformin
for diabetes prevention: an
intent-to-treat analysis of
the DPP/DPPOS. Diabetes
Care. 2012;35:723-730.
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DIABETES PREVENTION PROGR AM
FEB RUA RY 2 014
This CPM presents a model of best care based on the best available scientific evidence at the time
of publication. It is not a prescription for every physician or every patient, nor does it replace clinical
judgment. All statements, protocols, and recommendations herein are viewed as transitory and
iterative. Although physicians are encouraged to follow the CPM to help focus on and measure
quality, deviations are a means for discovering improvements in patient care and expanding the
knowledge base. Send feedback to Sharon Hamilton, Intermountain Healthcare, Primary Care
Clinical Program, [email protected].
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©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications CPM075 - 02/14 Minor update 10/2015