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

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2005 DEPTH Outcomes2005 DEPTH OutcomesAll People with DM vs DEPTH All People with DM vs DEPTH

CompletersCompleters

Blood Sugar Conrtol

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10%

20%

30%

40%

50%

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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

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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

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