1. Case Management and Diabetes Mellitus Shirley Descheenie-Effland, RN Suzanne Lipke, APRN, BC-ADM, CDE Charlton Wilson, MD

2. Diabetes Case Management Case management is part of the clinical component in which efforts are made to assist the client in achieving their highest level of diabetes self management.

3. Steps For Diabetes Case Management Assessment Assessment Analysis of assessment findings Analysis of assessment findings Outcome identification Outcome identification Planning Planning Diabetes Self Management Education Diabetes Self Management Education Evaluation Evaluation Follow up Follow up Program effectiveness Program effectiveness

4. Assessment Determine the priority of information obtained by the client’s immediate condition or need Determine the priority of information obtained by the client’s immediate condition or need Include the client’s family Include the client’s family Collect the information in a systematic manner Collect the information in a systematic manner Document findings in a retrievable format Document findings in a retrievable format

5. Assessment Integrate the assessment process with data from other members of the health care team to ensure continuity and collaboration Integrate the assessment process with data from other members of the health care team to ensure continuity and collaboration Include information related to client’s knowledge of diabetes and current diabetes self- management behaviors. Include information related to client’s knowledge of diabetes and current diabetes self- management behaviors.

6. Analysis of Assessment Identify actual or potential problems and/or challenges and barriers Identify actual or potential problems and/or challenges and barriers Identify interpersonal, cultural, psychosocial and environmental conditions that affect the client Identify interpersonal, cultural, psychosocial and environmental conditions that affect the client Validate findings with the client, family and health care team Validate findings with the client, family and health care team Document findings in a manner that identifies outcomes Document findings in a manner that identifies outcomes Incorporate findings into an individualized care plan Incorporate findings into an individualized care plan

7. Outcome Identification Formulate outcomes from assessment findings Formulate outcomes from assessment findings Determine that outcomes are realistic, attainable and measurable Determine that outcomes are realistic, attainable and measurable Ensure that outcomes reflect scientific knowledge of diabetes care Ensure that outcomes reflect scientific knowledge of diabetes care Use outcomes to evaluate goal attainment Use outcomes to evaluate goal attainment

8. Planning Assist client with developing goals Assist client with developing goals Patient selected plan - Individualize the plan to meet the client’s needs Patient selected plan - Individualize the plan to meet the client’s needs Identify priorities in relation to expected outcomes Identify priorities in relation to expected outcomes Document the plan Document the plan Collaborate with other team members about the plan Collaborate with other team members about the plan

9. Diabetes Self-Management Training Provide diabetes education that is pertinent to the client’s assessed needs and health values Provide diabetes education that is pertinent to the client’s assessed needs and health values Use appropriate teaching methods Use appropriate teaching methods Allow opportunities for the client to demonstrate skills Allow opportunities for the client to demonstrate skills Incorporate empowerment strategies Incorporate empowerment strategies Document understanding of education Document understanding of education

10. Evaluation Evaluate outcomes on a systematic and on-going basis Evaluate outcomes on a systematic and on-going basis Document client’s response to implementing the care plan Document client’s response to implementing the care plan Evaluate the effectiveness of interventions in relation to outcomes Evaluate the effectiveness of interventions in relation to outcomes Revises plan as needed Revises plan as needed Documents revisions Documents revisions Collaborates with team on evaluation Collaborates with team on evaluation

11. Follow - Up Determine frequency of follow-up Determine frequency of follow-up Use a systematic approach for each follow up visit Use a systematic approach for each follow up visit Provide client with feed back Provide client with feed back Incorporate a tracking system to avoid “lost to follow-up” status Incorporate a tracking system to avoid “lost to follow-up” status

12. Case Management Interventions Supportive Counseling Supportive Counseling Readiness for Change Readiness for Change Motivational Interviewing Motivational Interviewing Problem Solving Problem Solving Skills building Skills building Monitoring Monitoring Individualized Care Plans Individualized Care Plans Coordination of Resources Coordination of Resources

13. Things to Consider Age-appropriate, culturally, ethically and spiritually sensitive care and support Age-appropriate, culturally, ethically and spiritually sensitive care and support Educate patients, families and support systems Educate patients, families and support systems Continuity of care Continuity of care Coordination of care for various settings Coordination of care for various settings Managing information Managing information Effective communication with diabetes team Effective communication with diabetes team Non-judgmental approach Non-judgmental approach

14. Diabetes Case Managers Qualitative Experiences Developing inter-personal relationships helps to build trust Developing inter-personal relationships helps to build trust Persistence is required and rewarded Persistence is required and rewarded Individual assessment facilitates the development of a care and education plan Individual assessment facilitates the development of a care and education plan

15. Care Plan Using the PCC+ Form

21. Standing Orders Staged Diabetes Management Staged Diabetes Management

22.  -Glucosidase Inhibitors  -Glucosidase Inhibitor Dose Adjustments (in mg) StartNext Up to Max Acarbose25 mg/day25 mg bid25 mg tid100 mg tid Miglitol25 mg/day25 mg bid25 mg tid100 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)

23. Metformin Metformin Dose Adjustments (in mg) Start PMNext AM/PM Max AM/Mid/PM Metformin 500 mg 500500/500500/10001000/10001000/500/10 00 Metformin 850 mg 850850/850 850/850/850 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)

24. Sulfonylureas Sulfonylurea Dose Adjustments (in mg) Start AM Next AM Next AM/PM Max AM/PM Glyburide2.555/510/510/10 Micro.Glyburid e 1.536/-9/-12/- Glipizide51015/-10/1020/20 Glipizide XL51015/- 20/- Glimepiride123/-4/-8/- May be increased every 1-2 weeks. (From SDM Detection and Treatment Quick Guide)

25. Thiazolidinediones Thiazolidinedione Dose Adjustments (in mg) StartNextMax Pioglitazone153045 Rosiglitazone488 Thiazolidinedione dose may be adjusted every 8-12 weeks. (From SDM Detection and Treatment Quick Guide)

26. Combinations Glyburide/Metformin (Glucovance) Dose Adjustments (in mg glyburide / mg metformin) Start AM Or Start AM and PM Next AM/PM Max AM and PM Glucovanc e 1.25/250 mg 1.25/25 0 1.25/250 and 1.25/250 Glucovanc e 2.5/500 mg 2.5/500 and 2.5/500 5/1000 and 2.5/500 Glucovanc e 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)

27. Insulin Bedtime NPH Insulin Adjustments <80 mg/dl140-250 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

28. Insulin Insulin Stage 2 Pattern Adjustments RA/N – 0 – RA/N – 0 or R/N – 0 – R/N – 0 <80 mg/dl140-250 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/dl160-250 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).

29. Insulin Stage 3 Pattern Adjustments RA/N – 0 – RA – N or R/N – 0 – R – N <80 mg/dl140-250 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/dl160-250 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

30. Insulin Stage 4 Pattern Adjustments RA – RA – RA – N or G or R – R – R – N or G <80 mg/dl140-250 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/dl160-250 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

31. Insulin 70/30 Pattern Adjustments <80 mg/dl140-250 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/dl160-250 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

32. RPMS/DMS/EHR Examples Examples

33. DEPTH Registry Individualized to PIMC

44. AIc Clinical Benefits Clinical Benefits Educational Benefits Educational Benefits

45. 2005 DEPTH Outcomes All People with DM vs DEPTH Completers

48. Resources Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande- Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002; 22:15-38. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande- Kulis VG, Garfield S, Briss P, McCulloch D: The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002; 22:15-38. Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Implications for Workforce Development, Diabetic Medicine 2005; 22:1116-1120. Wilson, C, Curtis J, Lipke S, Bochenski C, Gilliland S, Description of the Case Load and Apparent Effectiveness of Nurse Case Managers in a Large Clinical Practice: Implications for Workforce Development, Diabetic Medicine 2005; 22:1116-1120.

49. Resources American Association of Diabetes Educators. The Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. The Diabetes Educator 2005; 31(4): 487-512. American Association of Diabetes Educators. The Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. The Diabetes Educator 2005; 31(4): 487-512.

50. Resources Coming Soon Best Practices in Diabetes Case Management Best Practices in Diabetes Case Management

51. Questions??