Care Coordination’s Diabetes Program is based on the Diabetes clinical guideline that incorporates recommendations from the American Diabetes Association’s Clinical Practice Recommendations and Staged Diabetes Management®.
The following is a description of the Diabetes Program and its elements.
Program Goals
The primary goal of the Diabetes Program is to minimize the morbidity and mortality of members with Type 1 and Type 2 while achieving the highest possible quality of life through the following clinical indicators:
- Incorporation of the Diabetes Clinical Guideline into a comprehensive health management program.
- Increase number of members with glycosolated hemoglobin (A1c) < 7.0%.
- Decrease frequency of the acute complications of diabetes (ketoacidosis,
hyperosmolar coma, severe hypoglycemia).
- Decrease frequency of chronic complications of diabetes (retinopathy, nephropathy, vasculopathy, neuropathy).
- Increase number of members with LDL < 100 mg/dL.
- Increase number of members with B/P < 130/80 mm Hg.
- Provide regular assessment and treatment of coronary heart disease risk factors.
- Perform annual monofilament foot examinations.
- Provide annual dilated retinal examination.
- Provide annual influenza immunization.
- Provide pneumococcal immunization when indicated.
- Increase number of members with microabluminuria that are treated with ACE Inhibitors or ARBs.
- Increase use of aspirin therapy in patients over age 30 at high risk of CV events.
Interventions
Care Coordination nurses work with health care providers and rely on the following interventions when working with Health Plan members enrolled in the diabetes program:
- Comprehensive diabetes assessment and risk assessment.
- Individualized self-management education–nutrition, exercise, glucose monitoring, medications, risk factor reduction, complication management, foot care.
- Coordination of glucose monitoring supplies.
- Collaboration with Primary Care Provider to promote best practice–standards of care, aspirin therapy, blood pressure and lipid management, ACE therapy, glycemic management, and referrals to specialists as indicated.
- Health promotion/disease prevention services–influenza and pneumococcal vaccines, mammograms, safety belts, etc.
- Data analysis to support clinical management–A1C, LDL, B/P, dilated eye exam, kidney screening, ASA use, ACE/ARB use and tobacco use.
Program Referral
To refer a Health Plan member to the Diabetes Care Program, providers may call (800) 833-6355 or (570) 271-8763, Monday through Friday, 8 a.m. to 4:30 p.m.
References
1. American Diabetes Association’s–2004 Diabetes Clinical Practice Recommendations
2. International Diabetes (IDC)–Staged Diabetes Management (SDM) Guidelines
3. Pennsylvania Medical Society–Medical Director’s Forum, Diabetes Care Workgroup, 2004
