Three Phases of the RGVCCM Program
Innovative program designed in partnership by local organizations to transform the delivery of chronic care management
for type 2 diabetes in the Rio Grande Valley of Texas (RHP 5). This program identifies participants with uncontrolled
diabetes (A1c >9) and recruits them to participate in a structured multi-disciplinary program to promote control and/or
improvement in the participants’ diabetes and overall health status, resulting in decreased acute care utilization over time.
During the transition care phase
The Transition Care (TC) Phase occurs during the first 21 days of program enrollment for participants with uncontrolled diabetes mellitus based on an HbA1c > 8.0%. The services occurring during the Transition Care period include: recruiting participants, ensuring participants are eligible for the program and dedicated towards diabetes self-management, conducting the Transition Care Assessment and the Behavior Change and Home Assessment; providing a review of Chronic Care Management (CCM) program services to the participant, sharing participant records with CCM team for review.
Chronic Disease Management Phase
Our Chronic Disease Management (CDM) program services typically lasts up to 180 days. The services provided during this time are designed to address the healthcare and other needs that are complex and often multifaceted for persons with uncontrolled diabetes. The services include support and education from a community health worker through home and telephone visits, skill building through evidenced-based diabetes self-management education classes, referral and navigation to a medical home, increased interaction with providers through group visits and text messaging, diabetes self-management support through chronic care team review and feedback, establishing a regular medical home (if one was not previously established) to ensure regular clinical visits occur, medication management, and referrals for ancillary services as necessary. The Chronic Care Management team and the participant will determine if an extension to the 180 days is medically appropriate to achieve diabetes control.
Follow-up Monitoring Phase
The Salud y Vida program also provides follow-up and monitoring. Participants will actively participate in the program for approximately 6 months. After this, some services will be provided and HBA1c levels will be obtained for up to 12 months. All participants will then be monitored by the team for an additional 12 months.
There are many benefits to the participants on the Salud y Vida: RGVCCM program. Participants will benefit from having access to our dedicated
team of health professionals who will provide participants with healthcare and support services to help them gain control of their diabetes.
Participants will benefit from getting a patient-centered approach through education, skills building, and support to help them live a healthy life.
More specifically, program participants will get:
- Access to free healthcare and support services (over $1500 value)
- A needs assessment by the Transition Specialist during the first appointment
- Access to six diabetes self-management education (DSME) classes
- A glucometer and test strips to monitor diabetes at home
- Appointments and access to a team of professionals who to monitor and treat diabetes
- Access to exercise classes
- Visits by community health workers for education, guidance and support
- Text message support
- HbA1c exam every 3 months
Participants will actively participate in the program for approximately 6 months. After this, some services will be provided and HBA1c
levels will be obtained for up to 12 months. All participants will then be monitored by the team for an additional 12 months.
|1-6 months||7-12 months||13-24 months|
|Transition Care Assessment|
|Home & Telephone Visits|
|Text message support|
|Obtaining HBA1c level|
|Monitoring health care|