Case Management and Diabetes Mellitus Shirley Descheenie-Effland, RN Suzanne Lipke, APRN, BC-ADM,...
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Transcript of Case Management and Diabetes Mellitus Shirley Descheenie-Effland, RN Suzanne Lipke, APRN, BC-ADM,...
Case Management Case Management and Diabetes Mellitusand Diabetes Mellitus
Shirley Descheenie-Effland, RNShirley Descheenie-Effland, RNSuzanne Lipke, APRN, BC-ADM, Suzanne Lipke, APRN, BC-ADM,
CDECDECharlton Wilson, MD Charlton Wilson, MD
Diabetes Case Diabetes Case ManagementManagement
Case management is part of the Case management is part of the clinical component in which efforts clinical component in which efforts
are made to assist the client in are made to assist the client in achieving their highest level of achieving their highest level of
diabetes self management.diabetes self management.
Steps For Diabetes Case Steps For Diabetes Case ManagementManagement
AssessmentAssessment Analysis of assessment findingsAnalysis of assessment findings Outcome identificationOutcome identification PlanningPlanning Diabetes Self Management EducationDiabetes Self Management Education EvaluationEvaluation Follow upFollow up Program effectivenessProgram effectiveness
AssessmentAssessment
Determine the priority of Determine the priority of information obtained by the client’s information obtained by the client’s immediate condition or needimmediate condition or need
Include the client’s familyInclude the client’s family Collect the information in a Collect the information in a
systematic mannersystematic manner Document findings in a retrievable Document findings in a retrievable
formatformat
AssessmentAssessment
Integrate the assessment process Integrate the assessment process with data from other members of the with data from other members of the health care team to ensure health care team to ensure continuity and collaborationcontinuity and collaboration
Include information related to Include information related to client’s knowledge of diabetes and client’s knowledge of diabetes and current diabetes self-management current diabetes self-management behaviors.behaviors.
Analysis of AssessmentAnalysis of Assessment Identify actual or potential problems Identify actual or potential problems
and/or challenges and barriersand/or challenges and barriers Identify interpersonal, cultural , Identify interpersonal, cultural ,
psychosocial and environmental psychosocial and environmental conditions that affect the clientconditions that affect the client
Validate findings with the client, family Validate findings with the client, family and health care teamand health care team
Document findings in a manner that Document findings in a manner that identifies outcomes identifies outcomes
Incorporate findings into an Incorporate findings into an individualized care planindividualized care plan
Outcome IdentificationOutcome Identification
Formulate outcomes from Formulate outcomes from assessment findingsassessment findings
Determine that outcomes are Determine that outcomes are realistic, attainable and measurablerealistic, attainable and measurable
Ensure that outcomes reflect Ensure that outcomes reflect scientific knowledge of diabetes carescientific knowledge of diabetes care
Use outcomes to evaluate goal Use outcomes to evaluate goal attainmentattainment
PlanningPlanning
Assist client with developing goals Assist client with developing goals Patient selected plan - Patient selected plan - Individualize Individualize
the plan to meet the client’s needsthe plan to meet the client’s needs Identify priorities in relation to Identify priorities in relation to
expected outcomes expected outcomes Document the planDocument the plan Collaborate with other team Collaborate with other team
members about the planmembers about the plan
Diabetes Self-Management Diabetes Self-Management TrainingTraining
Provide diabetes education that is Provide diabetes education that is pertinent to the client’s assessed pertinent to the client’s assessed needs and health valuesneeds and health values
Use appropriate teaching methodsUse appropriate teaching methods Allow opportunities for the client to Allow opportunities for the client to
demonstrate skillsdemonstrate skills Incorporate empowerment strategies Incorporate empowerment strategies Document understanding of educationDocument understanding of education
EvaluationEvaluation
Evaluate outcomes on a systematic Evaluate outcomes on a systematic and on-going basisand on-going basis
Document client’s response to Document client’s response to implementing the care plan implementing the care plan
Evaluate the effectiveness of Evaluate the effectiveness of interventions in relation to outcomesinterventions in relation to outcomes
Revises plan as neededRevises plan as needed Documents revisionsDocuments revisions Collaborates with team on evaluationCollaborates with team on evaluation
Follow - UpFollow - Up
Determine frequency of follow-upDetermine frequency of follow-up Use a systematic approach for each Use a systematic approach for each
follow up visitfollow up visit Provide client with feed backProvide client with feed back Incorporate a tracking system to Incorporate a tracking system to
avoid “lost to follow-up” statusavoid “lost to follow-up” status
Case Management Case Management InterventionsInterventions
Supportive CounselingSupportive Counseling Readiness for ChangeReadiness for Change Motivational InterviewingMotivational Interviewing
Problem SolvingProblem Solving Skills buildingSkills building
MonitoringMonitoring Individualized Care PlansIndividualized Care Plans Coordination of ResourcesCoordination of Resources
Things to ConsiderThings to Consider
Age-appropriate, culturally, ethically and Age-appropriate, culturally, ethically and spiritually sensitive care and supportspiritually sensitive care and support
Educate patients, families and support Educate patients, families and support systemssystems
Continuity of careContinuity of care Coordination of care for various settings Coordination of care for various settings Managing informationManaging information Effective communication with diabetes teamEffective communication with diabetes team Non-judgmental approachNon-judgmental approach
Diabetes Case Managers Diabetes Case Managers Qualitative ExperiencesQualitative Experiences
Developing inter-personal Developing inter-personal relationships helps to build trustrelationships helps to build trust
Persistence is required and Persistence is required and rewardedrewarded
Individual assessment facilitates the Individual assessment facilitates the development of a care and education development of a care and education planplan
Care PlanCare Plan
Using the PCC+ FormUsing the PCC+ Form
Standing OrdersStanding Orders
Staged Diabetes ManagementStaged Diabetes Management
-Glucosidase Inhibitors
-Glucosidase Inhibitor Dose Adjustments (in mg)
Start Next Next Up to Max
Acarbose 25 mg/day 25 mg bid 25 mg tid 100 mg tid
Miglitol 25 mg/day 25 mg bid 25 mg tid 100 mg tid
May be increased by 25 mg/day/week if tolerating dose; maximum dose of Acarbose is 50 mg tid for people who weigh <60 kg (132 lbs); clinically effective dose 50-100 mg tid before meals. (From SDM Detection and Treatment Quick Guide)
Metformin
Metformin Dose Adjustments (in mg)
Start PM Next AM/PM
Next AM/PM
Next AM/PM
Max AM/Mid/PM
Metformin 500 mg
500 500/500 500/1000 1000/1000 1000/500/1000
Metformin 850 mg
850 850/850 850/850/850
May be increased weekly when using 500 mg tablets or every other weekly when using 850 mg tablets. (From SDM Detection and Treatment Quick Guide)
Sulfonylureas
Sulfonylurea Dose Adjustments (in mg)
Start AM
Next AM
Next AM/PM
Next AM/PM
Max AM/PM
Glyburide 2.5 5 5/5 10/5 10/10
Micro.Glyburide
1.5 3 6/- 9/- 12/-
Glipizide 5 10 15/- 10/10 20/20
Glipizide XL 5 10 15/- 20/-
Glimepiride 1 2 3/- 4/- 8/-
May be increased every 1-2 weeks. (From SDM Detection and Treatment Quick Guide)
Thiazolidinediones
Thiazolidinedione Dose Adjustments (in mg)
Start Next Max
Pioglitazone 15 30 45
Rosiglitazone 4 8 8
Thiazolidinedione dose may be adjusted every 8-12 weeks. (From SDM Detection and Treatment Quick Guide)
Combinations
Glyburide/Metformin (Glucovance) Dose Adjustments (in mg glyburide / mg metformin)
Start AM
Or Start AM and PM
Or Start AM and PM
Next AM/PM
Max AM and PM
Glucovance 1.25/250 mg
1.25/250
1.25/250 and 1.25/250
Glucovance 2.5/500 mg
2.5/500 and 2.5/500
5/1000 and 2.5/500
Glucovance 5/500 mg
5/500 and 5/500
10/1000 and 10/1000
May be increased weekly when using 250 or 500 mg metformin tablets or every other weekly when using 1000 mg metformin tablets. (From SDM Detection and Treatment Quick Guide)
Insulin
Bedtime NPH Insulin Adjustments
<80 mg/dl 140-250 mg/dl >250 mg/dl
AM or 3:00 AM PM N 1-2 units
PM N 1-2 units
PM N 2-4 units
Insulin
Insulin Stage 2 Pattern AdjustmentsRA/N – 0 – RA/N – 0 or R/N – 0 – R/N – 0
<80 mg/dl 140-250 mg/dl >250 mg/dl
AM or 3:00 AM PM N 1-2 units
PM N 1-2 units
PM N 2-4 units
Midday AM RA or R 1-2 units
AM RA or R 1-2 units
AM RA or R 2-4 units
PM AM N 1-2 units
AM N 1-2 units
AM N 2-4 units
<100 mg/dl 160-250 mg/dl >250 mg/dl
Bedtime PM RA or R 1-2 units
PM RA or R 1-2 units
PM RA or R 2-4 units
Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide).
Insulin Stage 3 Pattern AdjustmentsRA/N – 0 – RA – N or R/N – 0 – R – N
<80 mg/dl 140-250 mg/dl >250 mg/dl
AM or 3:00 AM PM N 1-2 units
PM N 1-2 units
PM N 2-4 units
Midday AM RA or R 1-2 units
AM RA or R 1-2 units
AM RA or R 2-4 units
PM AM N 1-2 units
AM N 1-2 units
AM N 2-4 units
<100 mg/dl 160-250 mg/dl >250 mg/dl
Bedtime PM RA or R 1-2 units
PM RA or R 1-2 units
PM RA or R 2-4 units
Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide).
Insulin
Insulin Stage 4 Pattern AdjustmentsRA – RA – RA – N or G or R – R – R – N or G
<80 mg/dl 140-250 mg/dl >250 mg/dl
AM or 3:00 AM BT N or G 1-2 units
BT N or G 1-2 units
BT N or G 2-4 units
Midday AM RA or R 1-2 units
AM RA or R 1-2 units
AM RA or R 2-4 units
PM Mid RA or R 1-2 units
Mid RA or R 1-2 units
Mid RA or R 2-4 units
<100 mg/dl 160-250 mg/dl >250 mg/dl
Bedtime PM RA or R 1-2 units
PM RA or R 1-2 units
PM RA or R 2-4 units
Adjust insulin based on BG patterns (From SDM Detection and Treatment Quick Guide).
Insulin
Insulin 70/30 Pattern Adjustments
<80 mg/dl 140-250 mg/dl >250 mg/dl
AM PM 70/30 1-2 units
PM 70/30 1-2 units
PM 70/30 2-4 units
Midday AM 70/30 1-2 units
AM 70/30 1-2 units
AM 70/30 2-4 units
PM AM 70/30 1-2 units
AM 70/30 1-2 units
AM 70/30 2-4 units
<100 mg/dl 160-250 mg/dl >250 mg/dl
Bedtime PM 70/30 1-2 units
PM 70/30 1-2 units
PM 70/30 2-4 units
Insulin
RPMS/DMS/EHRRPMS/DMS/EHR
ExamplesExamples
DEPTH RegistryDEPTH Registry
Individualized to PIMCIndividualized to PIMC
AIcAIc
Clinical BenefitsClinical Benefits Educational BenefitsEducational Benefits
2005 DEPTH Outcomes2005 DEPTH OutcomesAll People with DM vs DEPTH All People with DM vs DEPTH
CompletersCompleters
0%10%20%30%40%50%60%70%80%90%
100%
Completio
n Rat
e
Attend
3 m
o f/u
Met
Exe
rcise
Goa
l
Post-K
nowled
ge=goo
d
Ac1 <
7.0%
SBGM
Eye
Dental
Foot (
neur
o)
UA/Micr
o
Nutrition
Visi
t
2005 Audit
2005 DEPTH
2005 DEPTH Outcomes2005 DEPTH OutcomesAll People with DM vs DEPTH All People with DM vs DEPTH
CompletersCompleters
Blood Sugar Conrtol
0%
10%
20%
30%
40%
50%
60%
<7.0 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9
11.0 + UNK
2005 Audit
2005 DEPTH
2005 DEPTH Outcomes2005 DEPTH OutcomesAll People with DM vs DEPTH All People with DM vs DEPTH
CompletersCompleters
Blood Pressure Control
0%
10%
20%
30%
40%
50%
<120/<
70
120/
70 -
130/
80
131/
81- <
140/<
90
140/
90 -
<160/
<95
160/
95 O
R HIG
HERUNK
2005 Audit
2005 DEPTH
ResourcesResources Norris SL, Nichols PJ, Caspersen CJ, Glasgow Norris SL, Nichols PJ, Caspersen CJ, Glasgow
RE, Engelgau MM, Jack L, Isham G, Snyder RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and McCulloch D: The effectiveness of disease and case management for people with diabetes. A case management for people with diabetes. A systematic review. systematic review. Am J Prev Med Am J Prev Med 2002; 22:15-2002; 22:15-38.38.
Wilson, C, Curtis J, Lipke S, Bochenski C, Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Managers in a Large Clinical Practice: Implications for Workforce Development, Implications for Workforce Development, Diabetic MedicineDiabetic Medicine 2005; 22:1116-1120. 2005; 22:1116-1120.
ResourcesResources
American Association of Diabetes American Association of Diabetes Educators. The Scope of Practice, Educators. The Scope of Practice, Standards of Practice, and Standards of Practice, and Standards of Professional Standards of Professional Performance for Diabetes Educators. Performance for Diabetes Educators. The Diabetes Educator 2005; 31(4): The Diabetes Educator 2005; 31(4): 487-512.487-512.
ResourcesResources
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Best Practices in Diabetes Case Best Practices in Diabetes Case ManagementManagement
Questions??Questions??