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.
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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
DeliverySystemDesign
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
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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..
DeliverySystemDesign
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
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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..
DeliverySystemDesign
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
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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.
DeliverySystemDesign
ClinicalInformation
Systems
Health SystemCommunity
Resources and Policies Health Care Organization
Chronic Care Model
Family Education & Self-Management
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
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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
…….
DeliverySystemDesign
ClinicalInformation
Systems
Health SystemHealth Care Organization
Chronic Care Model
Family Education & Self-Management
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
Resources and Policies
DeliverySystemDesign
ClinicalInformation
Systems
Health System
Health Care Organization
Chronic Care Model
Family Education & Self-Management
Support
• Partnerships• Key school contact identified• Input • Educational services available
Decision Support
Community
Resources and Policies
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.
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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!
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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
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• 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
Patient Education Handout
Patient Education Handout
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.
Mercy Clinics, Inc. Diabetes Education
--- 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
Mercy Clinics, Inc. Diabetes Education
--- 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
Patient Education Handout
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
Patient Education Handout
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.