Partners with the healthcare team, nutritionist and pharmacist to coordinate a comprehensive care plan for patients with diabetes; provides self-care education to a targeted population of diabetic members in order to improve disease control.

• In partnership with pharmacy and nutrition educators, and under the supervision of Regional Diabetes Program; educates patients and families for diabetes self-care: Builds relationships with teaching partners and Regional Diabetes Managers. Promotes, refers to, and advocates the InSTEP program. Collaborates with teaching partners and Regional Diabetes Program to schedule class dates and times to accommodate center patient population; serves as InSTEP program center lead. Conducts group classes using principles of adult learning and the standardized InSTEP with Diabetes curriculum. Assesses patient status, risk factors, and care needs to include self-management skills and factors/barriers to reducing risk. Establishes individual goal plan with patient and Provider. Facilitates and helps members develop a realistic personal action plan which promotes self-directed care. Evaluates patients progress towards goals and transitions to self-management once goals are met. Documents patient status, goal plan and progress per MAS Regional Diabetes Program Guidelines. Assists in evaluation of InSTEP program; completes and forwards required records in a timely manner. Actively manages Center Diabetes Registry to identify special needs and to reinforce self-management plan.