Chronic Conditions

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(Updated October 31, 2017)

Diabetes Definition:

Diabetes is a disease in which blood glucose levels are above normal. With diabetes, the body either doesn't make enough insulin or can't use its own insulin as well as it should. This causes sugar to build up in the blood. Diabetes can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations.  Centers for Disease Control

Diabetes Guidelines:

Michigan Quality Initiative Consortium Diabetes Management Guidelines

Diabetes Guidelines from the University of Michigan health System

2017 Diabetes Guidelines from the American Diabetes Association

Care Management Interventions:

Click Here for an example of a diabetes action plan

Diagnosis Specific Concerns

Care Management Intervention

Patient Specific Interventions

Care Manager Resources

Patient Resources


Assess patients knowledge level on diagnosis

Evaluate the need for initiating a referral to the local DSME program

Preparing for the visit Comprehensive Assessment tool

What to Expect at the Physician Appointment


Handout - Preparing for the Appointment

How a diabetes educator can help you

Diagnosis Education

Provide communication regarding the diagnosis

Help develop a diabetes action plan

Discuss diagnosis with care manager


Review educational materials provided


Provide teach-back


Printable Blood Glucose Log

Type 1 Diabetes

Type 2 Diabetes

MDHHS - Diabetes



Self-care behaviors for people with diabetes


Patient Education Handouts from Diabetes Care and Education


Diabetes Goal Tracker Mobile App


Medication Management

Complete full medication reconciliation


Provide education on prescribed Diabetes medications


If on insulin, educate patient on administration of insulin

Create medication list of all current medications including OTC and herbal supplements.


Demonstrate understanding of medications including:

  • Name and purpose
  • Dosage
  • When to take
  • How to refill


Provide teach back regarding medication administration


Blood Glucose Log

Tracking Blood Glucose

Pro Tips for Insulin Injections

Free or Low Cost Medications - MDHHS

All Medications Matter

Understanding Insulin

Learning How to Inject Insulin




Evaluate the need for initiating a referral to the local DSME program


Provide education on diet and tools for maintaining diet:

  • Counting carbohydrates
  • Glycemic Index
  • Good vs bad food
  • Reading food labels


Refer patient to a dietitian, nutritionist or diabetes educator


Create diet plan

Demonstrate understanding of diabetes meal plan:

  • Tip - Limiting foods that are high in sugar
  • Eating smaller portions, spread out over the day
  • Being careful about when and how many carbohydrates you eat
  • Eating a variety of whole-grain foods, fruits and vegetables every day
  • Eating less fat
  • Limiting your use of alcohol
  • Using less salt


Meet with diabetic educator


Follow recommended diet plan



What Can I Eat? from the ADA


Beginner's Guide to Carb Counting

Meal Planning from the ADA

Food Log

Symptoms of Hypoglycemia



Action Plan

Educate patient on when to call primary care physician


Provide patient with diabetes action plan

Demonstrate understanding of diabetes action plan and when to call physician’s office versus going to Emergency Room.

Review Diabetes Action Plan


Diabetes Medical Management Plan

Diabetes Action Plan

Diabetes Action Plan



Provide education on smoking cessation


Review materials provided on smoking cessation


Enroll in a smoking cessation program

Nurses: Help Your Patients Stop Smoking

Smoking: American Diabetes Association




Provide education on exercise  if recommended by physician


Create action plan

Provide examples of different types of exercise


Educate patient on signs and symptoms of when to stop exercising


Refer patient to Cardiac Rehabilitation if necessary by physician.


Check with provider prior to starting an exercise regimen


Understand warning signs and when to stop exercising

Follow recommended treatment plan

  • Tips- Start slowly
  • Exercise at the same time each day so it becomes a regular part of the day

Physical Activity, Exercise and Type II Diabetes

Physical Activity is Important

Physical Activity and Diabetes


Starter Walking Plan from the ADA





Discuss with patient the increased risk of blood vessel damage and peripheral neuropathy


Check BP


If a diagnosis of HTN, monitor BP daily

Controlling Hypertension in Patients with Diabetes

American Diabetes Association Position Statement Diabetes and Hypertension


Other Health Conditions

  • Provide information on complications of diabetes
    • Kidney disease
    • Vision
    • Blood pressure
    • Neuropathy
    • Heart disease


Diabetes and Infections

Nine Ways to Avoid Diabetes Complications

Living with Diabetes and potential complications, ADA


Healthy Eyes Matter


Healthy Feet Matter

Managing Stress

Refer patient to a behavioral health specialist


Educate patient on healthy ways to manage stress

Demonstrate understanding of healthy ways to manage stress


How Stress Affects Diabetes

Diabetes and Stress

Common Tests and Labs

Check A1C

Check fasting blood sugar

Educate on dangers of uncontrolled blood sugars

Check blood sugars daily

  • Daily log

Report abnormal blood sugars

Annual dilated eye exam

Annual dental appointment

Routine foot exams

Hemoglobin A1C Checking Your Blood Glucose
Vaccinations Educate patient on recommendation for vaccinations Discuss benefits of vaccines Vaccination of Adults with Diabetes - CDC Vaccination of Adults with Diabetes - CDC

For a printable version of the care manger interventions Click Here

This chart is not meant to be an inclusive list of interventions or resources for care management but a starting point in working with patients with diabetes. Always check with your practice regarding the use of guidelines, resources and education.



Diabetes Pathophysiology

An overview of type I and type II diabetes from WebMD


This section provides information on various toolkits to assist with the care management of diabetic patients.


Diabetes Toolkit

Diabetes toolkit from the University of Illinois at Chicago


Prevent Diabetes STAT Toolkit

Toolkit from the CDC and American Medical Association

Care Management Learning Resources

This section is for care managers who would like to get additional more specific information relating to diabetes.


Michigan Department of Health and Human Service Links

The links below provide resources for primary care


Diabetes Prevention Program - Michigan

Includes three strategic areas of focus and targeted goals and objectives to reduce the burden of prediabetes in Michigan.


Type II Diabetes Management

Diabetes Self-Management Education and Support for Adults with Type II diabetes from the American Diabetes Association.

Webinars and Presentations

MiPCT Webinar

Mar 13 2013

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Lisa Bosio, BSN, RN, CDE

MiPCT Care Management Webinar

Jun 24 2015

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Tammy Minor RN, BSN, CDE