Shelley Thorkelson CNM MSN CDE Diabetes in Pregnancy Case Manager Northern Navajo Medical Center Shiprock, New Mexico Se

1. Shelley Thorkelson CNM MSN CDE Diabetes in Pregnancy Case Manager Northern Navajo Medical Center Shiprock, New Mexico Service Unit

3. DM & Preg Project Goals Rapid identification of new cases Tracking daily appointed cases in clinics Monitoring case status and changes Supplying clinical and educational visits Tracking interventions & outcomes Statistical review Communication of findings and recommendations to clinical and support staff

4. Program Focus Reduction of perinatal morbidity & mortality statistics Increase Diabetes education & awareness for each family served Compile a usable data base for future studies.

5. Finding the Sweet Moms Rapid ID of New or Potential Cases RPMS Bulletins & QMAN Searches Daily Mailman Bulletins generated from ICD-9 Codes – 648.03, 683.83, and 648.93 Weekly Q-Man Queries of abnormal GTTs both 1hour and 3 hour results. Monthly lab report on all 2 hr GTTs done (this lab test in not currently in the Q-Man List of tests for potential query). Allows for FU on mothers who are now pre-diabetic or diabetic postpartum Male patients from this list are assigned to appropriate case managers for follow-up.

6. Sweet Mom Search cont., Appointments – DMS System – DA Function Registers are queried for appointed patients in facility clinics daily at 0800 Patients with pending GTTs and not on a register are tracked for appointments in the SCH section of RPMS

7. Case Data Tracking Enter Case into appropriate RPMS Register and onto hard copy Excel List CHO Intolerant (1 ABN Value on 3 hr GTT) GDM (2 or more ABN Values on GTT) PGDM (Pregestational Type 2 DM) ABN 1 HR GTT FU (needs 3 hr GTT) Establish DM & Pregnancy Program Case Management Flowsheet Form that tracks case progress, education topics covered, visit notes, etc.

8. RPMS Registers 101 Created within the CMS System Only the creator can add users/change parameters Name must include the word DIABETES to come up in the DMS menu DECC Diabetes DECC Pregestational Diabetes DECC Gestational Diabetes DECC CHO/INTOL Diabetes OFFSPRNG Diabetes Mom ABN 1 HR Diabetes Screen FU Registers Value Query of these special populations assist follow up care plans Are updated automatically when coders enter values/codes for complications, etc. Can be audited for quick status on SOC

9. Excel Hard Copy Rosters Why? No simple current way within RPMS to have a one page running list of all cases and data values to take with you on rounds, etc. Column Headings Plan ahead– what data do you want to track? Name/MR#/PCP/EDC/50gm/FBS/1HR/2HR/3HR/ 1TA1c/MNT/CM/Meter/Log ck/PO/Insulin/DEL Date/Type/Sex/MR#/BW/Category/PP Appt/2 HR Value/FU Notes/BF/BCM/FU Plan, etc.

10. Spread Sheet Template

11. Case Management Flowsheet Why yet another form? Single best way found so far to have the entire case status in one spot All topics discussed noted All referrals given are tracked All prenatal SOC parameters tracked Case Notes and Plans documented for quick recall Value of double charting – assists in continuity of care and plan adherence Eliminates endless searching thru PCCs for info

13. Tracking Nuts & Bolts Process Recipe: Check DMS DA Register Appointment Lists Q1-4 days Review SOC Audit – leave message for PCP Check RPMS Mailman Q 1-4 days – save #’s not on the list Review HS to determine if bulletin trigger accurate New Case: Enter into Excel, RPMS Register and start a Flowsheet Enter next appt in daily calendar – leave “send her over” note. Active Cases: Update flowsheet at each visit/chart pull/after delivery/end of year for stats. Updates: Review delivery log prn for birth data Follow-up PP – note 6 wk PP appt in RPMS SCH – enter on daily calendar – leave reminder “needs 2 HR GTT” for PCP. Review open pp cases periodically for lab values End of year pull all mom & baby charts – update/add data for accurate stats.

14. Value of the Portable Office Case Files Available Teaching Materials Supplies Instant Documentation Mobility Easy access for clients Continuity Organization

15. NNMC 2005 DM & Pregnancy Statistics Total Cases 105 13.5% of all pregnancies CHO – 17 GDM – 66 PGDM2 – 22 Maternal Birth Weights 46% Known SGA – 35% AGA – 48% LGA – 17% Mean Pre-preg BMI – 32 First Trimester A1c ^7% - 45% HTN Co-morbidity – 22% Antenatal Testing – 60% Kick Counting Documented– 34% SVD Rate – 60% Complication Rate – 55% Oligo/Poly/Fetal/Mec/PPH Birth Weights AGA – 52% SGA – 5% LGA – 43% Macrosomia – 34% Level 2 Nursery Care – 17% Hypoglycemia – 20% Jaundice – 28% Breastfeeding Rate – 74% Average duration – 11 weeks

16. NNMC 2006 DM & Pregnancy Statistics Total Cases 101 14 % of all pregnancies CHO – 17 GDM – 58 PGDM2 – 26 Maternal Birth Weights 32% Known SGA – 44% AGA – 15% LGA – 41% Mean Pre-preg BMI – 32 First Trimester A1c ^7% - 42% HTN Co-morbidity – 46% Antenatal Testing – 63% Kick Counting Documented– 88% SVD Rate – 52% Complication Rate – 58% Oligo/Poly/Fetal/Mec/PPH Birth Weights AGA – 55% SGA –4% LGA – 41% Macrosomia – 47% Level 2 Nursery Care – 34% Hypoglycemia – 18% Jaundice – 24% Breastfeeding Rate – 54% Average duration –9 weeks

17. Comparison 2004 & 2006 Stats Improved Areas h visits to CM/RD Time from Dx to DM Care Services h Sweet Success Log Eval visits h % using meters h antenatal testing for PGDM2 women h AGA rate for GDMs h PP visits for GDMs h PP GTTs done for GDMs Focus Areas MNT visits for GDMs Time from 1 to 3 HR GTTs US Eval rates Hyperglycemia in clinic visit – no trigger to DECC Eye exams for PGDM2 Antenatal testing for GDMs Big babies are even bigger Birth wts for PGDM2 PP DNKA rate/FU GTT Breastfeeding Rate

18. DM & Pregnancy Program Overview Questions?