1. Information about the lead provider
Describe your experience in prescribing prevention, lifestyle medicine, or type 2 diabetes prevention to patients. If you are currently providing diabetes prevention services or referrals, please indicate how long these services have been part of your practice.
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2. Background information about your practice setting
a. Describe the organizational capacity of your practice.
i. Include a brief overview of the size of your practice, the types of providers in your practice, the types of insurance you accept, the services you provide, and the population/communities you serve.
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ii. Include a description of your practice’s patient population.
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b. Describe your practice’s commitment to lifestyle change/ prevention.
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c. Describe any current activities implemented in type 2 diabetes prevention in your practice.
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2. Other individuals who would be involved in this project:
a. Contact information of other individuals involved in this project.
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b. How will they support your demonstration project? Please describe specific roles and responsibilities.
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3. Institutional support
a. How will your organization support your demonstration project?
i. Include any current EMR systems and other value-based care practices currently utilized by your organization that will be a part of your project.
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4. Current type 2 diabetes prevention practices implemented by your practice:
a. How do you currently identify (screen, test) and refer patients with prediabetes to diabetes prevention programs/services?
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b. What type of diabetes prevention program/service do you refer your patients to? Please choose from the list below, and provide a link to the program if applicable.
i. We do not currently patients to any diabetes prevention programs.
ii. CDC-recognized program (part of the National DPP)
iii. Other community-based diabetes prevention program not recognized by CDC
iv. Lifestyle change counseling within your practice setting
v. Lifestyle change counseling provided by you
1. What training and competencies do you have to provide lifestyle change counseling to your patients?
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5. Describe how you would use this grant to test innovative models to screen, test, and refer your patients with prediabetes to a CDC-recognized diabetes prevention program. Include the following information:
a. The prevalence of prediabetes and diabetes in your patient population.
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b. How will you screen patients for prediabetes (retroactive screening, proactive screening)?
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c. How will you conduct blood glucose testing for your patients who are screened and determined to be at risk?
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d. How will you refer your patients with prediabetes to a CDC-recognized diabetes prevention program?
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e. How will you follow up with your patients? How will you periodically check in with your patients and/or the organization that is providing the diabetes prevention program?
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f. Workflow
i. How will the screening, testing, and referral of your patients with prediabetes affect your workflow?
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ii. Identify ways in which you will manage your workflow.
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g. What tools/materials will you use to test the referral of your patients to a CDC-recognized diabetes prevention program in their community or online?
i. Provide a copy of the complete set of materials, including online links.
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ii. How will these tools/materials help you increase prediabetes screening, testing, and referral?
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iii. How will you test the effectiveness of the materials/tools that you utilized?
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h. What are your performance measures for the six-month demonstration project? Please be as specific as you can with your measures. Include no more than three performance measures
i. E.g.: I will increase the screening, testing, and referral of my patients with prediabetes by 15% during the six-month demonstration period.
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i. Preliminary evaluation plan for your demonstration project.
i. How will you determine the effectiveness of the tools that will be used to improve screening, testing, and referral processes for prediabetes?
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j. Sustainability plan for your demonstration project.
i. How will you continue to screen, test, and refer your patients with prediabetes to a CDC-recognized diabetes prevention program after the completion of the 6-month grant period?
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ii. How will your practice incorporate and institutionalize your screening and referral process into the clinic policy or EHR?
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6. Budget
a. Include a project budget for the amount requested. (Please provide the budget in a separate document.)
b. Include a budget narrative that clearly explains how you will your use the award to achieve the goals of the demonstration project.
i. E.g.: Will you use the grant money to hire a health professional to coordinate clinic workflow changes to enable prediabetes screening, testing, and referral; obtain data/feedback from the CDC-recognized diabetes prevention program on patients participating in the program; summarize the results of your demonstration project; and develop a sustainable screening/testing/referral protocol for your practice?
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7. Timeline: Include a clear and detailed timeline that includes
a. The start and the end dates for the 6-month demonstration project.
b. When and how often you will communicate with ACPM staff/ physician consultants.
c. When you will develop and submit the findings of the project.
QUESTIONS
If you have any questions about this application please email