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Purpose


Team meetings bring together key members of the care team and allow them to plan and coordinate their work better. Team meetings can serve to do the following:

  • Client segmentation: identify which clients are at highest risk, who needs more intensive follow-up
  • Assign clients to each CHW and agree on a schedule for how often these clients should be seen
  • Discuss current treatment plans for clients (particularly high-risk ones) and ensure everyone is in agreement with the plan.
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Role


The CHW should participate and provide input during these meetings. The CHW should also print out documents from the Registry for everyone to review.

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Prep

Each community should identify:

  • Who should attend the meeting. Typically meetings include doctors, nurses, the Health Director, and other staff involved in delivering diabetes care.
  • The chairperson for the meeting.
  • The person responsible for scheduling the meeting and frequency of meetings (e.g. every 2-4 weeks).
  • The person responsible for documenting actions agreed on in the meeting.
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Do

1. CHW prints off the “Latest Results” report from the Registry, makes copies and brings them to the meeting for team members.

2. Client Segmentation
The team reviews the Latest Results report and decides on which clients are deemed high-risk. One simple criteria is to decide that all clients with an A1c >= 10 are high-risk. The team is free to use other criteria it wishes to identify high-risk clients.

3. CHW Assignment
The team decides, generally by consensus, which high-risk clients should be assigned to which CHWs for the current time period.

4. Schedule Planning
The team decides how often each high-risk client should be seen. (For example, if a client is seen monthly by the doctor, then the team could decide that the CHW should see the client every two weeks between doctor visits.)

5. Treatment Goal Planning
The team discusses client’s current treatment goals. Ideally, this should be based on what the client has said he/she wants to do. The team then agrees to reinforce this goal at each opportunity. For example, if the client has told the doctor that she wants to walk 30 minutes every other day, then the CHW can ask the client how well she is doing with that goal and encourage her to stick to it.

6. Documentation
The person responsible for documenting the team meeting makes a master list of the high-risk clients, the CHWs assigned to each client, and treatment goals. This person distributes copies of this list to each CHW and keeps the original for review at the next meeting. Each person receiving a copy of this report is responsible for ensuring this report is kept in a locked or designated, secure place.

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Review


Download or use this online CHW sample form to practice the contents of this module.

Please note that these training modules are to be used for the purposes of CHW training in diabetes management. CHWConnect does not provide medical advice or specific diagnostic or treatment information.