Risk Score for Patient Engagement

Under each section, identify your patient’s specific condition and assign the related number. Total the numbers to determine the appropriate level of engagement.

HgbA1C Level

Blood Pressure

Statin Use

Recommendations for statin use vary depending upon age, gender, and other diabetes medications prescribed.

Recommendation for Engagement

5: Highest Risk

Active patient engagement. SHA Care Coordinator notification for patient engagement assistance. Follow weekly by Care Coordinator. Office visit q 90 days or more often. Assess for CDE opportunity or other intervention.

4: High Risk

Follow q 90 days. Activate SHA Care Coordinator for assistance in patient engagement and resources. SHA CC to follow weekly.

3: Medium Risk

Follow q 90 days. Activate SHA Care Coordinator for engagement prn or for appointment monitoring. Resource assistance provided by Care Coordinator as requested.

2: Low Risk

Follow q 6 months. Activate Care Coordinator if appointment not kept.

1: Lowest Risk

Follow q 6 months. Care Coordinator available for engagement assistance or appointment compliance.

Monitoring Criteria

For those Living Well with Diabetes

The Diabetes Composite Score, or D5 Diabetes Care score, is a scoring system focused on reducing the risk of the cardiovascular problems associated with diabetes. Care coordinators and other clinicians can use the score to monitor whether their patients are achieving the following standard five goals for living well with diabetes:

1. Maintaining a blood pressure lower than 130/80 mmHG
2. Having an LDL of less than 100 mg/dl
3. Maintaining blood sugar (A1C) of less than 7%
4. Not smoking
5. Taking aspirin daily, if the patient is over 40 years of age