Attachment C_CDM Activities.pdf

Attachment C: Chronic Disease Management Evidence-Based Intervention Examples

This list provides examples of eligible activities but is not a fully comprehensive list of all eligible activities. Other evidence-based interventions for chronic disease management may be proposed with sufficient justification.

Activity/Description Key Activities

Team-Based Diabetes Care Coordination

Implement a structured, team-based approach to diabetes management using nurse care managers, community health workers (CHWs), community health representatives (CHRs), or similar care coordinators to support patients with ongoing monitoring, follow-up, and care navigation.

• Assign a care coordinator for patients with uncontrolled diabetes

• Conduct regular care reviews (labs, medications, screenings)

• Coordinate referrals for eye exams, foot exams, and nutrition services

• Support transitions of care after hospital or emergency visits

• Provide additional screenings, including social drivers of health, mental health, food access, and medication access

• Create a community outreach program for high-risk patients

• Establish peer support groups

• Implement transportation assistance for patients who don’t have a way to get to appointments.

Diabetes Self-Management Education and Support

(DSMES)

Implement or expand an evidence-based diabetes self-management education program to build patient skills in medication adherence, nutrition, physical activity, and symptom monitoring.

• Offer group or individual DSMES sessions (in-person or virtual)

• Incorporate a virtual education platform

• Provide culturally appropriate education materials

• Incorporate goal setting and behavior-change coaching

• Link patients to community nutrition or wellness resources

Remote Patient Monitoring (RPM) for Diabetes

Use remote patient monitoring technologies to support proactive diabetes management for high-risk patients.

• Establish protocols for clinical review of home glucose monitoring device readings

• Conduct timely outreach when readings fall outside target ranges

• Integrate RPM data into the Electronic Health Record (EHR) or care management workflows

• Provide increased support and training for patients utilizing continuous glucose monitors.

Pharmacist-led Medication Management for Diabetes Incorporate pharmacist-led medication therapy management to optimize diabetes treatment regimens.

• Provide patient education on medication use and adherence and side effects, including over-the-counter medications.

• Staff training on continuous glucose monitor reports and troubleshooting

• Establish partnerships with primary care providers

• Establish tele-pharmacy options for rural patients

Standardized Hypertension and Cardiovascular Disease Care Protocols Implement standardized, evidence-based treatment protocols for hypertension and cardiovascular disease using team-based care approaches.

• Adopt guideline-based blood pressure treatment algorithms

• Establish nurse- or pharmacist-supported medication titration protocols

• Implement policy on routine blood pressure checks and follow-up workflows

• Implement clinical decision support within Electronic Health Records

• Support community blood pressure screening events with structured follow-up care

Remote Patient Monitoring (RPM) for Hypertension and Heart Failure (i.e., Self-Measured Blood Pressure Program) Use home monitoring and virtual follow-up to proactively manage patients with hypertension or heart failure.

• Provide home blood pressure cuffs through a loaner program

• Work with patients to monitor readings

• Implement a two-week follow-up visit that includes medication or symptom review

• Implement early intervention for worsening symptoms

• Provide education for decreasing risk and/or management of high blood pressure

Medication Therapy Management for Cardiovascular Disease Expand pharmacist-led or team-based medication therapy management for patients with cardiovascular disease.

• Complete comprehensive medication reconciliation and review to verify and update all prescription, OTC, and supplement use; identify discrepancies, duplications, drug–drug interactions, contraindications, and gaps in therapy; and ensure an accurate

• Perform evidence-based medication optimization to align therapy with current cardiovascular guidelines, including titration of antihypertensives and statins, optimization of heart failure regimens, deprescribing when appropriate, addressing cost barriers, and collaborating with providers to improve safety, adherence, and clinical outcomes

• Targeted focus on high-impact cardiovascular therapies, including antihypertensives, statins, antiplatelet agents (as indicated), and guideline-directed heart failure medications.

• Address polypharmacy and adherence management, including assessment of medication burden, simplification of regimens, identification of side effects, and implementation of adherence supports (e.g., synchronization, blister packaging, reminder systems).

• Provide patient education on medication safety, the purpose of each medication, potential side effects, and the importance of taking medications as prescribed and not discontinuing medications without a pharmacist's order.

Healthy Lifestyle South Dakota Program Provide structured lifestyle and risk-reduction support to patients with or at risk for chronic disease. Healthy Lifestyle SD enables all providers with an online platform, apps, and content for the virtual delivery of the Lifestyle Programs.

• Expand or initiate DSMES (Diabetes Self-Management Education and Support) programs

• Become an accredited DSMES provider to support underinsured/uninsured patients

• Integrate DSMES into care plans for patients with diabetes.

• Include digital tools like Continuous Glucose Monitors (CGMs) and digital scales for better engagement

• Deliver Evidence-Based Lifestyle Programs to patients

• Implement National Diabetes Prevention Program (DPP) for patients at risk of type 2 diabetes.

• Offer Healthy Lifestyle Coaching sessions virtually or onsite.

• Provide Self-Measured Blood Pressure (SMBP) Hypertension Management programs for patients with high blood pressure.

• Enable telehealth and virtual coaching sessions.

• Host webinars or workshops on chronic disease prevention.

• Collaborate with local employers, schools, and community groups for referrals.

Patient Reminders for Cancer Screenings Send patient reminders via mail, text, phone, auto dialer, patient portal, etc., to patients who are due or overdue

• Send patient reminders, either written or electronic, advising people they are due for breast, cervical, and/or colorectal cancer screening, as well as HPV vaccination.

for a breast, cervical, or colorectal cancer screening, or HPV vaccination.

Decrease Barriers to Cancer Screening Decrease structural, non-economic barriers or obstacles that make it difficult for people to access cancer screening.

• Organize mobile mammography testing events with procedures in place for follow-up care

• Establish processes and provide stool-based tests for colorectal cancer screening in eligible patients

• Offer extended service hours for cancer screenings

• Provide patient navigation and individualized support to ensure completion of necessary steps

• Create systems to screen and address social drivers of health that may impact participation in cancer screenings

Cancer Screening Provider Supports Enhance cancer screening delivery through clinical decision support, patient-provider communication strategies, and ongoing performance monitoring.

• Integrate provider reminders into Electronic Health Records, ensuring that providers are notified when a patient is due or overdue for cancer screening

• Implement strategies to support shared decision-making between providers and patients about prostate and lung cancer screening

• Evaluate provider performance in delivering cancer screenings through the implementation of provider assessments

Cancer Survivorship Care Systems Strengthen systems of survivorship care for childhood cancer survivors and their families.

• Support coordinated approaches that improve access to high-quality survivorship care

• Promote long-term health and well-being

• Address ongoing needs of cancer survivors and their families across the lifespan.

Cognitive, Functional, and Safety Support Interventions Implement interventions or refer to services that support cognitive function, daily living, and safety for individuals with Alzheimer’s Disease and related dementias.

• Implement cognitive stimulation activities appropriate to disease stage

• Support activities of daily living using occupational therapy–informed strategies

• Implement home safety assessments and fall-prevention education for people living with dementia

Telehealth-Enabled Dementia and Caregiver Support Use telehealth to expand access to dementia care and caregiver support in rural communities.

• Virtual dementia assessments and follow-up visits o Provide virtual cognitive screening and diagnostic assessments using validated tools o Conduct caregiver-reported functional and behavioral assessments o Provide regular virtual follow-up visits to monitor cognitive and functional status

• Implement teleconsultation with geriatric or neurology specialists that includes:

o Provider-to-provider e-consult pathways for diagnostic clarification and medication management o Regular virtual case review conferences with complex patients o Offer direct-to-patient virtual visits with specialists when appropriate

Advance Care Planning and Goals-of-Care Integration Integrate early and ongoing advance care planning into routine dementia care.

• Establish a standardized process to initiate and document advance care planning discussions at diagnosis and annually thereafter.

• Train staff to conduct structured goals-of-care conversations and provide culturally appropriate education on dementia progression and decision-making.

• Offer dedicated advance care planning visits (in-person or telehealth) for patients and caregivers.

• Integrate advanced directives and care preferences into the EHR with routine review and updates.

• Develop formal referral and warm handoff pathways to palliative care and hospice services

Address Barriers to Health with Community Health Workers/Community Health Representatives (CHWs/CHRs) Integrate CHWs/CHRs into care plans for chronic conditions.

• Utilize CHWs/CHRs to connect clients to community resources for food, housing, transportation, and financial assistance.

• Provide health education on chronic disease management, preventive care, and medication adherence.

• Help patients navigate the healthcare system, including scheduling appointments and attending visits.

• Conduct home or community visits to identify needs and advocate for services.

Chronic Disease Care Coordination

• Conduct comprehensive assessments and develop individualized chronic disease care plans with patients.

• Facilitate communication and care coordination among primary care, specialists, and support staff.

• Provide patient education and self-management support for medication adherence, lifestyle, and symptom monitoring.

• Schedule routine follow-ups and use remote monitoring to track patient progress.

• Link patients to community resources, social support, and assistance programs as needed.

• Track outcomes and implement quality improvement strategies to close gaps in care.

This project is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. department of Health and Human Services (HHS) as part of the Rural Health Transformation Project, a financial assistance award totaling $189,477,607.26 with 100% funded by CMS/HHS. The contents are those of the South Dakota DOH and DSS and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

Updated: March 2026