Gayle Curto, RN, BSN, CDE Clinical Coordinator

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1 Gayle Curto, RN, BSN, CDE Clinical Coordinator

2 INTRODUCTION Historical Program Overview Leadership Team Mission Statement Diabetes Center Demographics for 2011 Older Adult Population

3 HISTORICAL PROGRAM OVERVIEW Became Outpatient Center 1991 ADA Recognized Program 1988 Disease Management Program 1998 TJC- Disease Specific Certification 2006 Inpatient Diabetes Education RN, CDE s & 1 RD, CDE RN, CDE s & 3 RD, CDE s

4 LEADERSHIP TEAM Jane Willemsen, President, CAO, JMH, Walnut Creek Campus Debra Pendergast, RN, MSN, NEA-BC, SVP of Patient Care Services/Chief Nursing Officer Patrick Watson, SVP of Care Coordination and Integration Douglas W. Zlock, M.D., Medical Director Gayle Curto, RN, BSN, CDE, Clinical Coordiantor

5 MISSION STATEMENT We are dedicated to improving the health of the community we serve with quality and compassion. Our objective is to provide comprehensive and compassionate health education that will help our patients live an active healthy life with diabetes. Our goal is to empower these individuals to effectively manage their diabetes and to reduce the risk of acute and long term complications.

6 Diabetes Self Management Education Continuum of Care Physician Diabetes Education Team PATIENT Other Health Care Professionals Diabetes Self Management Skills

7 DIABETES MELLITUS SCOPE OF PROBLEM Affects 26 million Americans Older Adult Population (> 65 years) 11 million or ~27% have diabetes # is expected to grow rapidly in the coming decades Direct/indirect costs: $174 billion and counting Increased prevalence will put more burden on US health care system * Huang, Elbert, et al. Diabetes Care, Vol 32, No 12 Dec 2009 Projecting the Future Diabetes Population Size and Related Costs for US

8 DIABETES CENTER DEMOGRAPHICS 2011 Ethnicity Number of Patients Percentage Caucasian % Asian/Pacific Islander % Hispanic % African American 94 5% Native American 5 0.3%

9 DIABETES CENTER S VOLUME 2011 New Patients 80-90/month 177 Referring Physicians 2011 patient visits 6791 Historical 2010 patient visits patient visits 7813

10 BREAKDOWN OF VOLUME Patient Population- Total Patients 1957 Type 1 Diabetes 80 4% Type 2 Diabetes % Gestational Diabetes % Pre-Diabetes 87 5% Age % % % % % %

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12 Diagnostic Criteria Normal glucose levels Fasting glucose is 60 to 99 mg/dl After meals usually < 140 mg/dl At Risk /Pre-Diabetes Fasting glucose between mg/dl Postprandial glucose between mg/dl A1C % Diabetes Mellitus Fasting glucose > 126 mg/dl A1C > 6.5% Any glucose 200 mg/dl or greater with symptoms

13 Medicare Guidelines Diabetes : 10 hours of initial DSME training within a continuous 12-month period One of the hours can be given on a one-on-one basis. Initial assessment The other 9 hours of training are given in a group class. Special need allows for 1-1 education MNT 3 hours of initial training 2-4 hours of follow up each year (DSME+MNT) At Risk /Pre Diabetes: No coverage for education 2 hour self pay education class: Basics of Diabetes Prevention Program Normal glucose control Risk factors Prevention strategies: Healthy eating, 30 minutes of activity most days of the week, modest weight loss (if needed) Blood pressure and cholesterol targets Regular medical follow up

14 MEDICARE SELF MANAGEMENT PROGRAM Initial assessment with RN Diabetes 101 class Glucose Control, Medications, Exercise, BG Monitoring, A1C Healthy Eating for Blood Glucose Control Carbohydrate Portions, Reading Labels, Alcohol Meet with the Dietitian - MNT Beyond the Basics Sick Day Management, Travel, Resources, Complication Prevention Become a Fat Detective Good Fats/Bad Fats, Dining Out, Lipids, Blood Pressure Insulin Basics and Advanced Insulin Principles RN Follow up Set behavior change goals 3-6 month follow up Evaluate plan and goals

15 Glycemic Goals Glucose goals: Preprandial glucose mg/dl, Peak postprandial glucose < 180 mg/dl A1C < 7 % Individualize glucose goals when needed

16 ADA Guidelines for the Treatment of Older Adults With Diabetes Intensive therapy (same goals as younger people) appropriate for older adult patients who are: Expected to live long enough to reap benefits (~10 y) Cognitively intact Able to undertake self management Treating CV risk factors in older adults may have a greater impact on reducing morbidity and mortality than tight glycemic control Treat older adults with same drug regimens as younger patients, using special care in prescribing and monitoring

17 Important Considerations For Determining BG and A1C Targets Age Duration of diabetes/longstanding diabetes Cardiovascular risk factors Comorbid health conditions Patient/family goals Level of cognition Physical disabilities Living situation

18 Ideal Ranges pre meal < 180 post meal A1C (eag) < 7% (154) Glycemic Targets Safe Ranges for older adults pre meal < 200 post meal A1C (eag) < 8% (183)

19 2011 A1C Data For the Center s Population of % 532 patients 27% patients 36% 7-8% 328 patients 17% 8-9% 153 patients 8% 9-10% 86 patients 5% 10-12% 19 patients 3% >12% 10 patients <1% 2011 average A1C % in goal range (< 7%) 9% of total population have an A1C > 9%

20 DISEASE MANAGEMENT PROGRAM Yearly Visit: Foot screening tuning fork, reflex hammer, checking pulses, monofilament check Blood Pressure - sitting/standing Skills review with RN and diet review with RD Height, weight, order yearly labs (Fasting Lipid, A1C, TSH, CBC, Microalbumin Creatinine Ratio GFR/Serum Creatinine, Complete metabolic panel Annual Retinal Exam Routine lab every 3-6 months A1C and glucose/meter check (patient compares meter to fasting lab glucose) RN Visit every 4 months Lab review Foot screening Weight and blood pressure check Glucose records/medication review/dose adjustments per protocol 2013 Lipid Protocols for cholesterol management

21 ADDITIONAL FEATURES Diabetes Exercise Program Coordinated with Cardiac Rehabilitation Department Senior Services Balance classes Women s Health Center Offer a variety of classes Continuous Glucose Monitoring Sensor placed for one week for 24/7 glucose pattern review Nurse Driven Protocols Insulin Start (Basal/Bolus) and Adjustment Basal insulin start is based on age and weight Foot Care PI Quick Look Foot magnet Foot poster Motivational Photos

22 IN-PATIENT DIABETES EDUCATION Survival Skill Education Flex RN, CDE s 2 hours a day Insulin packets for Type 1 and Type 2 Educate the most complicated patients Newly diagnosed Prior history/needs review A1C > 7.5 on admission New on insulin and/or new medication regimen Insulin pump DKA, HHNS Severe hypoglycemia or hyperglycemia Steroid therapy

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