Pathway 3 – Monitoring: Educate Team Members and Patients about Appropriate Monitoring Intervals or Implement Clinical Decision Support within Your Record System

Diabetes has become an epidemic of mass proportions that can only be overcome through clear practice guidelines, a clinical understanding of a patient’s contextual barriers to care, and a priority to maximize the practice team to implement meaningful patient interventions. As part of your practice improvement plan, in addition to the screening intervention, please select one of the seven diabetes management interventions below to implement in your practice:


  • Implement standing orders for monitoring tests for patients with diabetes
  • Have a patient education initiative to inform patients about needed tests to monitor their diabetes
  • Start utilizing a clinical decision support tool within your record system to ensure that patients with diabetes receive appropriate monitoring tests

Primary Guidelines

American Diabetes Association

For additional information, please view the Clinical Introduction & References.

Resources & Tools

American Diabetes Association (ADA)
  • What Can I Eat program is a train-the-trainer nutrition program that could be easily incorporated into a practice that is already providing DSME. Some programs use it as a precursor to DSME and some use it as a refresher course for folks who have already done DSME.
American Medical Association (AMA)
Centers for Disease Control and Prevention (CDC)
  • National Diabetes Prevention Program (DPP)
    A 12-month CDC-recognized, evidence-based lifestyle change program for preventing type 2 diabetes that empowers individuals with prediabetes to take charge of their health and well-being by making real lifestyle changes in nutrition, physical activity, and problem-solving/coping skills.
Ohio Academy of Nutrition & Dietetics
Health Policy Institute of Ohio
Health Services Advisory Group
National Association of Chronic Disease Directors
National Diabetes Education Program
Stanford Medicine
  • Diabetes Self-Management Program (DSMP)
    A 6-week workshop for people with type 2 diabetes that teaches the skills needed in the day-to-day management of diabetes and how to maintain and/or increase life’s activities.
U.S. Preventive Services Task Force (USPSTF)


American Heart Association Patient Stories
AMA: Primary Care Best Practice
CDC Patient Stories Patient Stories
Nebraska Medical Center Patient Stories
Type 2 Diabetes Prevention (Ad Council)

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