organization of diabetes care

Organization of Diabetes CareOrganization of Diabetes Care

Alireza Esteghamati,MDAlireza Esteghamati,MD

Professor of Endocrinology and MetabolismProfessor of Endocrinology and Metabolism

Tehran University of Medical SciencesTehran University of Medical Sciences

The Chronic Care ModelThe Chronic Care Model

Improving Care for People Living Improving Care for People Living with diabeteswith diabetes

ObjectivesObjectives

Define the Define the problem in today’s health care systemsproblem in today’s health care systems

State State 5 useful aims 5 useful aims to keep in mind while seeking to to keep in mind while seeking to improve careimprove care

Describe the development of Describe the development of the Chronic Care Model the Chronic Care Model (CCM)(CCM)

List the List the 6 components 6 components of the CCMof the CCM

Key PointsKey Points

1.1. Diabetes is a chronic disease that requires Diabetes is a chronic disease that requires proactive, proactive,

planned and population-based careplanned and population-based care

2.2. It takes a teamIt takes a team. Diabetes care should involve a . Diabetes care should involve a

interdisciplinary team interdisciplinary team working within the chronic care working within the chronic care

modelmodel

3.3. TechnologyTechnology (telehealth, reminder systems, EMRs, etc.) (telehealth, reminder systems, EMRs, etc.)

can can be used to be used to improveimprove care care

A New Health system for the 21st CenturyA New Health system for the 21st Century

““The current care systems The current care systems can notcan not do the do the job.”job.”

““Trying harder will not work.”Trying harder will not work.”

““ChangingChanging care systems will.” care systems will.”

Six Aims for Improving Health SystemsSix Aims for Improving Health Systems

SafeSafe: avoids : avoids injuries injuries ((no needless deaths, accidents, or injuries)no needless deaths, accidents, or injuries)

EffectiveEffective: relies on latest: relies on latest scientific knowledgescientific knowledge

Patient-centeredPatient-centered: responsive to patient needs, values, and : responsive to patient needs, values, and preferencespreferences

TimelyTimely: avoids delays: avoids delays

EfficientEfficient: avoids waste : avoids waste

EquitableEquitable: quality unrelated to: quality unrelated topersonal characteristics (personal characteristics (everyone, everywhere can receive )everyone, everywhere can receive )

Implications for How to Change PracticeImplications for How to Change Practice

If the If the problem is the systemproblem is the system, and , and not the not the individual “bad apples,” individual “bad apples,” then the focus for then the focus for practice improvement needs to shift.practice improvement needs to shift.

Need to make the right thing to do Need to make the right thing to do the easy the easy thing to do. thing to do.

7

Usual Chronic Illness CareUsual Chronic Illness Care

15 minute visit, 15 minute visit, poorly poorly organizedorganized

Symptoms and lab results Symptoms and lab results focus of discussion and focus of discussion and exam, exam, not preventive not preventive assessment assessment

Patient’s Patient’s attempts to discuss attempts to discuss difficulties difficulties in living with the in living with the condition are condition are discourageddiscouraged

Usual Chronic Illness CareUsual Chronic Illness Care

Focus is on physician’s Focus is on physician’s treatment, not patient’s role in treatment, not patient’s role in management.management.

Treatment plan is limited to Treatment plan is limited to prescription prescription refill and refill and encouragement to make encouragement to make appointment if not feeling wellappointment if not feeling well

Visit ends with physician rifling Visit ends with physician rifling through drawers looking for a through drawers looking for a pamphlet pamphlet

Rationale for Population Based CareRationale for Population Based Care

The current care delivery system was design for acute The current care delivery system was design for acute episodic care episodic care and does a and does a poor job for chronic and preventive poor job for chronic and preventive care. Until there is fundamental system change we will not care. Until there is fundamental system change we will not

do much better than the following:do much better than the following:

Evidence based careEvidence based care given only given only 55%55% of time of time– (NEJM. 2003;348(26):2635-2645)(NEJM. 2003;348(26):2635-2645)

Blood sugarBlood sugar is controlled in only is controlled in only 37%37% of patients with of patients with diabetes diabetes – (JAMA. 2004:291(3):335-342)(JAMA. 2004:291(3):335-342)

Blood PressureBlood Pressure is controlled in only is controlled in only 35%35% of patients with of patients with hypertensionhypertension– (Ann Intern Med. 2006;145(3):165-175)(Ann Intern Med. 2006;145(3):165-175)

““Every system is perfectly designed Every system is perfectly designed to get the results it gets”to get the results it gets”

Uninformed,

PassivePatient

FrustratingProblem-Centered

Interactions

UnpreparedPractice Team

Sub-optimalFunctional and Clinical Outcomes

Delivery System DesignReliance on short, unplanned visits

Decision SupportNo agreement on good care; traditional referrals

Clinical Information SystemsDon’t know pts or what they need

Self-Management SupportNo systematic approach; didactic in orientation

Health System

Resources and Policies•No links with community agencies or resources

Community Health Care Organization•Leadership concerned about the bottom line•Incentives favor more frequent, shorter visits•No organized QI

Usual Care Model

Reality: Guidelines are NOT FollowedReality: Guidelines are NOT Followed

Care gap between diabetes management Care gap between diabetes management guidelines and real-life practiceguidelines and real-life practice

Organizational and evidence-based Organizational and evidence-based approach to treating chronic diseasesapproach to treating chronic diseases

Real Life

IdealPractice

Chronic Care for a Chronic DiseaseChronic Care for a Chronic Disease

Acute and reactive Acute and reactive

Proactive, planned, and population-basedProactive, planned, and population-based

The Chronic Care Model

15

ToTo Change Outcomes Change Outcomes RequiresRequires Fundamental Practice ChangeFundamental Practice Change

Reviews of interventions in several conditions show Reviews of interventions in several conditions show that that effective practice changes are similar across effective practice changes are similar across conditions.conditions.

Integrated changes Integrated changes with components directed at:with components directed at:•Influencing Influencing physicianphysician behavior behavior

• Better use of Better use of non-physician team membersnon-physician team members

• Enhancements to Enhancements to information systemsinformation systems

• PlannedPlanned encountersencounters

• Modern Modern self-management supportself-management support

• Care management for high risk patientsCare management for high risk patients

Satisfaction Clinical Measures Cost External Review Measures

Prepared, Proactive

Practice Team

Supportive, Integrated Community

Productive Interactions

Chronic Care ModelChronic Care Model

Informed, ActivatedPatient

Functional and Clinical Outcomes

Themes in the Chronic Care ModelThemes in the Chronic Care Model

Evidence-basedEvidence-based

– Valuing excellence (Valuing excellence (and evidence) over autonomyand evidence) over autonomy

Patient-centeredPatient-centered

– Each patient is the only patientEach patient is the only patient

Population-basedPopulation-based

Supportive, Integrated Community

Productive Interactions

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Health SystemResources and PoliciesCommunity

Health Care Organization

The Chronic Care Model

Family Education &

Self- Management Support

Prepared,Proactive

Practice Team

Informed,Activated Patient

Elements of the Chronic Care ModelElements of the Chronic Care Model

1. Delivery Systems Design: The Team

2. Self-ManagementSupport 3. Decision

Support

4. Clinical Information

Systems

5. Community

6. Health Systems


ClinicalInformation

Systems

Health SystemHealth SystemHealth Care Organization

Chronic Care Model

Family Education & Self-Management

Support

• Specific goals in organizations strategic/business plan• Senior leader support• Organization adopts performance improvement model•Provider incentives support organizational goals

Decision Support

Community

Resources and Policies

22

Health Care OrganizationHealth Care Organization

Visibly support improvement at all levels, Visibly support improvement at all levels, starting with starting with senior leaders.senior leaders.

Promote effective improvement strategies Promote effective improvement strategies aimed at aimed at comprehensive system change.comprehensive system change.

Encourage open and Encourage open and systematic handling of problemssystematic handling of problems..

Provide incentivesProvide incentives based on quality of care.based on quality of care.

Develop agreements for care coordinationDevelop agreements for care coordination..


ClinicalInformation

Systems

Health SystemResources and Policies

Community Health Care Organization

Chronic Care Model

Family Education & Self- Management Support

• Evidence-based guidelines• Provider education• Referrals and specialist expertise• Guidelines for patients

Decision Support

24

Decision SupportDecision Support

Embed evidence-based Embed evidence-based guidelines into daily guidelines into daily clinical practice.clinical practice.

IntegrateIntegrate specialist expertise and primary care. specialist expertise and primary care.

Use proven Use proven providerprovider educationeducation methods. methods.

ShareShare guidelines and information guidelines and information with patientswith patients..


ClinicalInformation

Systems

Health System Community

Resources and Policies Health Care Organization

Chronic Care Model

• Emphasize patient/parent active role•Collaborative care planning/problem solving• Ongoing educational process• Connections between family/patient and social support• Standardized assessments of self-management• Written management plan with goal setting

Decision Support

Family Education & Self-Management Support

Self-Management SupportSelf-Management Support

Formerly known as Diabetes EducationFormerly known as Diabetes Education

Shift from Shift from didactic diabetes educationdidactic diabetes education to a to a patient-empowering motivationalpatient-empowering motivational approach approach

Problem-solvingProblem-solving and and goal-settinggoal-setting

28

Self-Management SupportSelf-Management Support Emphasize the patient's central role.Emphasize the patient's central role.

Use effective self-management support strategies Use effective self-management support strategies that include:that include:

assessment assessment

goal-settinggoal-setting

action planning action planning

problem-solving problem-solving

follow-up.follow-up.

Organize resources to provide support. Organize resources to provide support.


ClinicalInformation

Systems

Health SystemCommunity

Resources and Policies Health Care Organization

Chronic Care Model


Support

• Team roles and tasks (practice team, school, parents) • Care based on accepted guidelines• Primary care team assures continuity• Regular follow-up care

Decision Support

30

Delivery System DesignDelivery System Design

Define roles Define roles and and distribute tasks distribute tasks among team members.among team members.

Use planned interactions Use planned interactions to support evidence-based careto support evidence-based care..

Provide clinical case management services for high risk Provide clinical case management services for high risk patients.patients.

Ensure regular follow-up.Ensure regular follow-up.

Give care that patients Give care that patients understand and that fits their cultureunderstand and that fits their culture..

Delivery Systems Design: The TeamDelivery Systems Design: The Team

Expertise of nurses, dietitians, pharmacists, and Expertise of nurses, dietitians, pharmacists, and psychological supportpsychological support

Team working Team working with with primary care primary care physicians supported by physicians supported by specialistsspecialists

Disease management model that uses patient education, Disease management model that uses patient education, coaching, treatment adjustment, monitoring, care co-coaching, treatment adjustment, monitoring, care co-ordinationordination

YouYOU

Optometrist or ophthalmologist

Local diabetes education centre

Foot care specialistMental Health Professional

Other people you know who have diabetes

Physical activity specialist

Dentist

Heart specialist

Kidney specialist

Family and friends

Your diabetes care team may include a

…….


ClinicalInformation

Systems

Health SystemHealth Care Organization

Chronic Care Model


Support

• Registry to track clinically useful and timely information • Registry reports/data for feedback • Care reminders• Assure timely planned follow-up • Identification/proactive care of relevant patient subgroups• Individual patient care planning

Decision Support

Community



ClinicalInformation

Systems

Health System

Health Care Organization

Chronic Care Model


Support

• Partnerships• Key school contact identified• Input • Educational services available

Decision Support

Community


36

Community Resources and PoliciesCommunity Resources and Policies

Encourage patients to participate in effective Encourage patients to participate in effective programs.programs.

Form partnerships with community Form partnerships with community organizations to support or develop programs.organizations to support or develop programs.

Advocate for policies to improve care.Advocate for policies to improve care.

39

Essential Element of Good Chronic Essential Element of Good Chronic Illness CareIllness Care

Informed,Activated

Patient

ProductiveInteractions

PreparedPractice

Team

40

What characterizes an “informed, activated What characterizes an “informed, activated patient”?patient”?

Informed,Activated

Patient

They have the motivation, information, skills,They have the motivation, information, skills, and confidence necessary to and confidence necessary to

effectively make decisions abouteffectively make decisions about their health and manage it.their health and manage it.

Informed, Activated, Patient

Patient understands the disease process and realizes his/her role as the daily self-manager

Family and caregivers are engaged in the patient’s self-management

The provider is viewed as a guide on the side, not the sage on the stage!

42

What characterizes a “prepared” What characterizes a “prepared” practice team?practice team?

PreparedPractice

Team

At the time of the interaction they have At the time of the interaction they have the patient information, decision support, and the patient information, decision support, and

resources necessary to deliver resources necessary to deliver high-quality care. high-quality care.

Prepared Practice TeamPrepared Practice Team

Has the:Patient informationDecision supportPeopleEquipmentTime

To deliver:Evidence-based clinical managementSelf-management support

44

• Assessment of self-management skills and Assessment of self-management skills and confidence as well as clinical status.confidence as well as clinical status.

• Tailoring of clinical management by stepped Tailoring of clinical management by stepped protocol.protocol.

• Collaborative goal-setting and problem-solving Collaborative goal-setting and problem-solving resulting in a shared care plan.resulting in a shared care plan.

• Active, sustained follow-up.Active, sustained follow-up.

Informed,Activated

Patient

ProductiveInteractions

PreparedPractice

Team

How would I recognize aHow would I recognize aproductive interaction?productive interaction?

Self-Management EducationSelf-Management Education

Self-Management Education (SME)Self-Management Education (SME)

A systematic intervention that involvesA systematic intervention that involves

active patient participationactive patient participation

in self-monitoring in self-monitoring and/orand/or

decision-makingdecision-making

Key PointsKey Points

1.1. Diabetes self-management education (SME) Diabetes self-management education (SME) improves health parametersimproves health parameters

2.2. SME should SME should teach behaviours as well as knowledge teach behaviours as well as knowledge and and technical/problem-solving skillstechnical/problem-solving skills

3.3. SME should be SME should be patient-centredpatient-centred, tailored to the , tailored to the individual, use a variety of teaching methods and be individual, use a variety of teaching methods and be regularly reinforcedregularly reinforced

Knowledge is PowerKnowledge is Power

Empowering patients through self-Empowering patients through self-management education improves:management education improves:

– A1CA1C– Quality of lifeQuality of life– Weight lossWeight loss– Cardiovascular fitnessCardiovascular fitness

Basic Knowledge and SkillsBasic Knowledge and Skills

Monitoring health parameters (including SMBG])Monitoring health parameters (including SMBG]) Healthy eatingHealthy eating Physical activityPhysical activity Pharmacotherapy and medication adjustmentPharmacotherapy and medication adjustment Hypo-/hyperglycemia prevention/managementHypo-/hyperglycemia prevention/management Prevention and surveillance of complications Prevention and surveillance of complications Problem identification and solvingProblem identification and solving

Not Just Knowledge: Work on BehaviorNot Just Knowledge: Work on Behavior!!

Cognitive-behavioral interventions Cognitive-behavioral interventions improve self-management and metabolic improve self-management and metabolic outcomes outcomes

They may involve:They may involve:– Cognitive re-structuringCognitive re-structuring– Problem-solvingProblem-solving– Cognitive-behavioural therapy (CBT)Cognitive-behavioural therapy (CBT)– Stress managementStress management– Goal settingGoal setting– Relaxation Relaxation

How should SME be delivered?How should SME be delivered?

Interdisciplinary team and/or peer-education

Personal contact with healthcare workers

Combination of group and individual sessions

Combination of didactic and interactive

Steps to SuccessSteps to Success

Self-Management SupportSelf-Management Support

This section contains:This section contains: 5A’s Self-Management support forms5A’s Self-Management support forms Goal Setting formGoal Setting form Patient education handoutsPatient education handouts

Using the 5 “A’s” With DiabetesUsing the 5 “A’s” With Diabetes

Assess Assess Advise Advise Agree Agree Assist Assist ArrangeArrange

Using the 5 “A’s” With Using the 5 “A’s” With DiabetesDiabetes

Assess:Assess: What does the patient know about What does the patient know about diabetes. Are they ready to learn? What are diabetes. Are they ready to learn? What are their values and culture?their values and culture?

Advise:Advise: Prioritize an individual plan for your Prioritize an individual plan for your patient in partnership with them.patient in partnership with them.

Agree:Agree: Start with goals patient has identified Start with goals patient has identified and assist them in creating ways to meet their and assist them in creating ways to meet their goals.goals.

Using the 5 “A’s” With Using the 5 “A’s” With DiabetesDiabetes

Assist: Assist: Develop a long-term plan for the Develop a long-term plan for the patients which is agreed upon by both patient patients which is agreed upon by both patient and provider. Assist patient in identifying and provider. Assist patient in identifying barriers to success. barriers to success.

Arrange:Arrange: Continue to follow-up and assist Continue to follow-up and assist patientpatient

5A’s Self Management Support Form

Specific for Diabetes

Patient Name: ______________________ Date:___________

Self-Management Education – Diabetes

Assess patients knowledge, beliefs, behaviors, and clinical data. Does patient have the desire to change behavior? Yes No Advise about health risks and benefits of change - consider health literacy. Topics Discussed:

Diet Home glucose monitoring Kidney disease HgA1c ADA standards of care Exercise Eye Care Hypertension, CV disease Aspirin Foot care Hyperlipidemia Hypoglycemia Insulin Medication compliance Other

Agree on a goal based on patient priorities. *Patient Goal: ____________________________________________ Assist To develop a person action plan.

1. Specific behavior changes

2. Identify barriers (? depression)

3. Options to address barriers

4. Follow up plan - When : ____________ How: Phone Other ___________ Educator Signature:_______________________

Arrange: to contact the patient between visits. *Follow-up Contact: Completed on - Date:___________

1. Results of Behavior changes

2. Barriers encountered

3. Options to address barriers

4. Follow up plan - When : ____________ How: Phone Other _________

Follow-up Signature:_____________________

*Required to bill Wellmark (Individual visit - S9445)

Patient Education ToolsPatient Education Tools

Help patients Help patients prepare for, prepare for, and know what and know what to expect from, to expect from, a diabetes visit a diabetes visit

I f y o u h a v e D I A B E T E S , h e r e a r e s o m e t h in g s y o u c a n t a lk a b o u t w it h y o u r h e a l t h c a r e p r o v id e r

C h o o s e t o t a lk a b o u t c h a n g in g a n y o f th e s e a n d a d d o t h e r c o n c e r n s in t h e b la n k c ir c le s .

B lo o d P r e s s u r em o n i t o r in g

T a k in g m e d i c a t io n s t o h e l p c o n t r o lb lo o d p r e s s u r e

L o s in g w e ig h t

D a i ly f o o t c a r e

D e p r e s s io n

S m o k in g

S k in c a r eA v o id in gs t r o k e s

o r h e a r td is e a s e

D ie t

Diabetes

Self Management

Goal Setting Form

Diabetic Patient Goals and Progress

HOW WELL HAVE YOU MET YOUR DIABETIC GOALS SINCE YOUR LAST VISIT? 1=Not Met, 2= Attempted to meet, 3=Somewhat Met/Some Progress,

4=Almost Met, 5=Completely Met Goal

Start Date: Visit Date

Visit Date

Visit Date

Visit Date

Visit Date

Visit Date

Visit Date

Visit Date

Goal 1: I will exercise (walk) 30 minutes _____ days per week. If I notice chest pain, shortness of breath or chest tightness, I will seek medical attention.

Goal 2: I will check my feet daily. If I notice a sore or irritation I will seek medical attention. I will visit the Podiatrist yearly, or as instructed.

Goal 3: I will follow my diabetic and low fat diet to reduce my blood sugar and cholesterol.

Goal 4: I will try to obtain my ideal body weight. I will lose _____ pounds by my next office visit.

Goal 5: I will stop smoking.

Goal 6: I will check my blood sugar as instructed and will call if the results are consistently below 70 or above 150. I will bring my blood sugar log book to every visit with my provider.

Goal 7: I will talk about how I feel about having diabetes to family, friends and/or a chaplain. I will attend a Diabetes Support Group.

How can we help you meet your goals?

Keep your blood sugar under control to prevent damage to many parts of the body, such as the heart, blood vessels, eyes and kidneys

For most people, good blood sugar levels are

What should my blood sugar numbers be ?

How can I find out what my average blood sugar is?

The hemoglobin A-1-c (HE-moh-glow-bin A-1-c) blood test shows the average amount of sugar in your blood during the past 3 months. Have this test done at least twice a year. A test result of more than 7 percent is too high. At more than 7 percent you need a change in your diabetes plan. Your doctor can help you decide what part of your plan to change. You may need to change your meal plan, your diabetes medicines, or your exercise plan.

Keep your hemoglobin A-1-c below 7 percent

On waking (before breakfast) 80 to 120 Before meals 80 to 120 2 hours after meals 180 or less At bedtime 100 to 140

Mercy Clinics, Inc. Diabetes Education

--- Blood Sugar Goals

Mark your hemoglobin A-1-c on this chart.

Patient Education Handout

Too much cholesterol can clog your blood vessels. This can cause heart attacks and strokes. You should check your Cholesterol at least once a year.

Cholesterol Diabetes Education

To lower my Cholesterol I will: Lose weight Walk for 20 minutes on most days Eat a low fat diet

read labels and don’t eat foods with more than 20 grams of fat per serving Eat more fruits and vegetables Avoid fried foods, desserts, and oils

Take medicine if I can’t get my LDL less than 100

For health blood vessels Keep your LDL less than 100

A Cholesterol blood test has four parts: 1. Total Cholesterol: Less than 200 2. LDL Cholesterol: Less than 100 (Bad Cholesterol) 3. Triglycerides: Less than 200 (like bacon grease) 4. HDL Cholesterol: More than 45 (Good Cholesterol)

Your number should be

My LDL is: ______________

Medicines to lower cholesterol: Statin drugs (Lipitor, Zocor, Pravechol,

Lescol) are used to lower cholesterol Take these in the evening at supper or

bedtime These can make your muscles ache Do cholesterol blood tests every four

months if you take these medicines



Diabetes and high blood pressure often go hand-in-hand. If you have heart, eye, or kidney problems from diabetes, high blood pressure can make them worse. You will see your blood pressure written with two numbers separated by a slash. For example: 120/70 Keep your first number below 130 and your second number High Pressure can damage your heart, below 85. eyes, kidneys, and brain.

To lower my blood pressure I will:

Lose weight Eat more fruits and vegetables Eat less salt and high-sodium foods

such as: o canned soups

o luncheon meats

o salty snack foods

o fast foods Drink less alcohol

Walk for one-half hour on most days

Keep your blood pressure below 130/85 You may need to take blood pressure medicine. An ACE inhibitor is the best type because it can slow down kidney damage by keeping the kidneys from losing too much protein. Take your medicine every day unless your doctor tells you to stop.


--- High Blood Pressure

How Much Should You Weigh? All foods can raise you blood sugar The more you eat – the higher your sugar The most important diet advise is

Don’t over-eat If you are over-weight you should lose weight The only ways to lose weight are:

Eat less – smaller portions Exercise more – such as walking

If you take diabetes medicine you should not skip meals – it can cause low blood sugar

Eat More: Vegetables & Fruits -Five or more servings a day Fish and Chicken (without the skin)

Eat Less: Starches such as potatoes, rice, pasta, bread,

corn Milk and Yogurt

-Use Skim Milk Red Meat, Eggs, Cheese

Avoid: Fats – if any use olive or canola oil Sweats - no pop except diet Alcohol - never more than 2 drinks a day

Height Weight Women Men

5-0 137 144 5-1 140 147 5-2 143 150 5-3 147 153 5-4 151 156 5-5 155 160 5-6 159 164 5-7 163 168 5-8 167 172 5-9 170 176 5-10 173 180 5-11 176 184 6-0 179 188


--- Diabetes and Diet

Eat a wide variety of foods Avoid salt Don’t eat fried foods Don’t add butter, sauces or dressings Be careful in restaurants

-portions are too big -there are too many fats and sauces


The difference in insulin is the time that it is working after you inject it. Onset of Action: This is how long it takes for the insulin to start

lowering your blood sugar. Peak Action: This is the time after injection when the insulin will lower

your sugar the most. Duration of Action: This is how long it takes for the insulin to wear off

and no longer work to lower you blood sugar.

Type of Insulin

Class of Insulin

Onset of Action

Peak Action

Duration of Action

Humalog Short Acting 15 Min. 1 Hr. 3 Hrs. Regular Short Acting 30 Min. 2-3 Hrs. 6 Hrs. NPH Intermediate 3 Hrs. 6-8 Hrs. 18 Hrs Lantus Long Acting 1 Hr. None 24 Hrs.

The best way to use Insulin is to prevent your sugar from ever going too high rather than lowering a sugar once it is too high.

When you inject insulin you are trying to prevent your sugar from going too high after your next meal or future meals.

The following table tells you what insulin to adjust if your sugars have been out of control in the past few days.

Before Breakfast

Before Lunch

Before Supper

Before Bedtime

Humalog - Breakfast H-log Lunch H-log Supper H-log Regular Breakfast Reg Lunch Reg Supper Reg

NPH Bedtime NPH - Breakfast NPH - Lantus Lantus

For example if your lunch time sugars have been:

Too high - you should increase you breakfast Humalog (or Regular) Too low - you should decrease your breakfast Humalog (or Regular)

--- How to use Insulin Mercy Clinics, Inc. Diabetes Education


The Chronic Care Model (CCM) Saves LivesThe Chronic Care Model (CCM) Saves Lives

The CCM improves:The CCM improves:1.1. A1C A1C

2.2. LDL-CLDL-C

3.3. Use of statinsUse of statins

4.4. Drug and hospital expenditures Drug and hospital expenditures

5.5. Overall mortality Overall mortality

Key Changes for Diabetes Self-Management Decision Support Clinical

Information System

Delivery System Design

Organization of Health Care

Community

Use diabetes self-management tools that are based on evidence of effectiveness

Embed evidence-based guidelines in the care delivery system.

Establish a registry. Use the registry to review care and plan visits.

Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement and business plans.

Establish linkages with organizations to develop support programs and policies.

Set and document self-management goals collaboratively with patients

Establish linkages with key specialists to assure that primary care physicians have access to expert support.

Develop processes for use of the registry, including designating personnel for data entry, assuring data integrity, and registry maintenance.

Assign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capability.

Make sure senior leaders and staff visibly support and promote the effort to improve chronic care.

Link to community resources for defrayed medication costs, education, and materials.

Train physicians and other key staff on how to help patients with self-management goals.

Provide skill-oriented interactive training programs for all staff in support of chronic illness improve-ment.

Use the registry to generate reminders and care-planning tools for individual patients.

Use planned visits in individual and group settings

Make sure senior leaders actively support the improvement effort by removing barriers and providing necessary resources.

Encourage participation in community education classes and support groups.

Follow up and monitor self-management goals.

Educate patients about guidelines.

Use the registry to provide feedback to care team and leaders.

Make designated staff responsible for follow-up by various methods, including outreach workers, telephone calls, and home visits.

Assign day-to-day leadership for continued clinical improvement.

Raise community awareness through networking, outreach, and education.

Use group visits to support self-management

Tap community resources to achieve self-management goals.

Use promotoras and community health worker programs for outreach.

Integrate Collaborative Models into the Quality Improvement program.

Provide a list of community resources to patients, families, and staff.

organization of diabetes care

Documents

selfmanagement status

features of case management

daily selfmanagerfamily

health care process

primary care

highquality care

chronic care issues

diabetes education