Primary Care Provider Toolkit

Diabetes Care and Resources for the Care Team

  • Promote self-management by coaching the Member to set personal goals that are Specific, Measurable, Attainable, Realistic and Trackable.
  • Involve people who support the Member (providers, family, caregivers) when developing a care plan.
  • Work one on one with high-risk Members to slow the progression of their conditions. Empower them to make quality health care decisions.  Educate them about their chronic conditions and how to avoid complications.
  • Promote healthy lifestyle choices by referring the Member to smoking cessation courses or educational classes like diabetes self-management classes.
  • Connect the Member to appropriate medical, behavioral and social services to maintain needed care delivery.
  • Find specialists and arrange appointments for specialty services within the Member’s network. Facilitate the appropriate exchange of health information between the Member’s PCMP and specialty care, behavioral health and ancillary care providers to ensure seamless delivery of care.
  • Assist the Member with transportation needs and with food security needs related to diabetes.
  • Reconcile all prescribed medications, and help the Member understand how to take medications appropriately.
  • Regularly contact the Member to assess compliance with the care plan, and offer needed education and support.
  • Counsel Members who visit the ER frequently. Help them understand when it is okay to call their PCP office or the Nurse Advice Line before going to the ER.
  • Alert the Provider when a Member is not compliant and at risk for deterioration or hospitalization.

  • Diabetes Self-Management Education and Support (DSMES) is an evidence-based intervention that strengthens the knowledge and skills of people with diabetes to optimize their ability to self-manage their disease. DSMES teaches participants how to eat healthy, be active, monitor blood sugar levels, take medication, problem solve, reduce risk for other health conditions, and cope with their disease. It is evidence-based and improves clinical outcomes, health status and quality of life.


Arkansas Valley Regional Medical Center in La Junta
Monthly diabetes self-management and training classes (type 1, type 2 and gestational) including refresher classes and a monthly diabetes support group. Other services include telehealth and continuous glucose monitoring.
Contact Information
Questions about services:  719-383-6017
Questions about referral paperwork:  719-383-6591
Fax:  719-383-6031
https://www.avrmc.org/

High Plains Community Health Center in Lamar, Wiley and Holly
Free diabetes education classes, cooking classes and health coaching
Contact Information
Tel: 719-336-0261
Fax: 719-336-0265
http://www.highplainschc.net/getpage.php?name=services

Mt. San Rafael Hospital in Trinidad
Diabetes Self-Management Classes
Contact Information
Call 719-846-2206 for more information.
http://www.msrhc.org/getpage.php?name=Diabetic_Education&sub=Our%20Services

Parkview Medical Center in Pueblo
Diabetes Self-Management Classes
Contact Information
Diabetes Care Center Tel:  719-584-7320
Fax:  719-584-7304
https://www.parkviewmc.com/classes-events/details/?eventId=79e08870-5678-ea11-a82e-000d3a611c21

San Luis Valley Health in Alamosa, Monte Vista and La Jara
San Luis Valley Health Diabetes Education and Empowerment Program (DEEP):  services include a class series and refresher education for anyone who has received diabetes self-management training in the past.
Contact Information
Stuart Avenue Clinic (Alamosa) Tel:  719-589-8008
Monte Vista Community Clinic and La Jara Medical Clinic Tel:  719-587-1309 or 719-589-8095
Fax to DEEP:  (719)-587-5770
https://www.sanluisvalleyhealth.org/services/diabetes-education/