RECOGNIZE: Appropriately screen for & identify people with diabetes ▪ Limited screening due to limited resources and patients screened elsewhere by other providers ▪ Used existing records/registries (e.g., chronic diseases lists, CARE EHR, Physician EMR) ▪ Relied on patient self-referral or engagement with healthcare system | |
REGISTER: Develop a means of tracking all patients with diabetes ▪ Used patient charts or chronic diseases lists, paper-based and/or electronic ▪ Data entry in the context of limited resources was problematic ▪ Relied on patient self-referral or engagement with healthcare system | |
RESOURCE: Support self-management through inter-professional teams ▪ Differential access to diabetes-related providers and services, including diabetes educators or programming ▪ Limited ability to support patients in context of limited resources ▪ Lack of collaborative care between healthcare providers ▪ Relied on patient self-referral or engagement with healthcare system | |
RELAY: Information sharing between patient & healthcare team members ▪ Used Netcare, CARE EHR, or Physician EMR ▪ Facilitators: colocation of healthcare workers and providers; existing relationships ▪ Barriers: privacy concerns; limited access to data or data systems; or incompatibility of Physician EMRs with CARE EHR resulting in data entry | |
RECALL: Remind caregivers & patients of timely review & reassessment ▪ Used CARE EHR, patient chart review, or chronic diseases lists; patient reminders ▪ Barriers: patients not engaging with healthcare system (e.g., no shows even when recalled); limited use of CARE EHR by all staff; time consuming, not knowing who had T2D) |