Table 1 Mobile Diabetes Education Team (MDET) intervention components, timelines and content

RN initial visit

Patient’s first visit with RN, one hour

Assessment: Time-span with diabetes; diabetes knowledge; recent hospital admissions; medication regime and adherence; lab blood work review; medical history; blood pressure; foot exam; capacity for SBGM and/or results review; current exercise regime; presence of diabetes complications; risk management for new and existing acute and long-term complications; proper identification of diabetes.

Education: What is diabetes?; how medications work; signs and symptoms of high and low blood sugars; how to reduce long-term complications; benefits of exercise; SBGM technique and timing; how to interpret SBGM results; sharps disposal; stress management; foot care.

Teach as needed: Insulin time action; insulin administration and technique; titrating doses; sick day management; travel glucagon and ketones.

RD initial visit

Patient’s first visit with RD, one hour

Assessment: Effects of food, exercise and medications on blood glucose levels and cholesterol; lab blood work review; weight history and goals; fast food consumption; meal composition and timing; specialty foods, supplements, and alcohol use; food allergies; disordered eating.

Education: Healthy eating guidelines; meal planning, food choices and portion size; carbohydrate load and consistency; major food nutrients; specialty food and sweeteners; fiber, fats, sodium, and alcohol; eating out.

Teach as needed: Carbohydrate counting; glycemic index; insulin carbohydrate ratio.

Action plan and goal setting

At initial MDET visits, and ongoing

MDET helps patient find behaviors they would like to initiate or change; patient and MDET collaboratively create action plan and set goals. This may include a referral to a local DEP for additional support (for example, cooking demos, and so on). Goals are then shared with the PCP.

Collaborative patient care/Patient case conferencing

Following each patient visit with MDET

MDET communicates with PCP through face-to-face meetings or using a communication tool to review major obstacles to good diabetes control and make recommendations about medication changes to help improve control for the patient. Goals are decided upon by the patient as what they would like to work on before the next visit, and are reinforced by the PCP on following visits.

MDET follow-up visits

30 minutes x 3 visits over 1-year period

Assessment: Patients’ success in achieving established goals; future goals; SBGM results and recent blood work to determine diabetes control; effectiveness of medication and lifestyle changes.

Education: Teach topics listed in RN and RD initial visit guidelines, based on identified issues from first initial visit, patient questions and follow-up assessment.