The purpose of this implementation guide is to describe key lessons learned from the evaluation of the Diabetes and Hypertension Self-Management Education (DHSME) model implemented within the Shands Jacksonville Patient-Centered Medical Home (PCMH) (referred to as Shands Jacksonville in this report). This guide is intended for public health practitioners who are interested in implementing chronic disease self-management education models that reduce or remove barriers to healthcare while also strengthening community-clinical linkages. If you are a health system or PCMH administrator or state health department program manager, you may wish to use this document as you consider a DHSME model and think about its core elements. Its core elements are infrastructure and capacity, care coordination processes, strategic partnerships, and health information exchange (HIE).

The lessons learned from Shands Jacksonville’s DHSME can apply in different community settings or with different patient populations, including those who are disproportionately burdened by chronic disease. When using this guide, consider the unique needs and assets of your patient population, as well as the unique characteristics of your community setting to enhance your ability to tailor the DHSME model’s core elements.

Suggested citation: Centers for Disease Control and Prevention. Implementation Guide for Public Health Practitioners: The Shands Jacksonville Patient-Centered Medical Home Diabetes and Hypertension Self-Management Education Model. Atlanta, GA: U.S. Dept of Health and Human Services; 2015.

shands-implementation-guide.pdf

Stephen B. Thacker CDC Library collection