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Monthly Diabetes Team Meeting

Monthly Diabetes Team Meeting. First Things First. Purpose . Achieve DM quality goals using the Chronic Care Model FMC, team, individual physician Demonstrate Residents’ Practice Based Learning & Improvement Demonstrate leadership in care team Use database to assess practice quality

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Monthly Diabetes Team Meeting

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  1. Monthly Diabetes Team Meeting First Things First

  2. Purpose • Achieve DM quality goals using the Chronic Care Model • FMC, team, individual physician • Demonstrate Residents’ Practice Based Learning & Improvement • Demonstrate leadership in care team • Use database to assess practice quality • Propose & complete PDSA cycle • Teach evidence based practice

  3. Initial DM Quality Goals • > 70% have Self management Goals • > 60% HgbA1c < 7% • > 40% BP < 130/70 • > 70% LDL < 100 • Eye exam, monofilament, microalbumin Q yr • Depression screen each visit • <12% current smoking • ACE/ARB

  4. The Chronic Care Model

  5. Expectations • Every month before PGY2/3 core • If unable to schedule before PGY2/3 core, then team decides on alternate • Meeting lasts ≤ 30 min • Work will occur outside meeting • All faculty, PGY3, PGY2, RNs • Representatives from ancillary staff

  6. Agenda • Preparation • Review team and personal DM quality • FMC quality data report • Team report on PDSA cycle • Resident presentation related to PDSA • Team meetings to suggest next PDSA

  7. Chronic Care Portfolio • Perform data base query • Propose, complete, report PDSA cycle • Update, present chronic care topic • Case study difficult chronic care patient • Self management goal setting

  8. The Chronic Care Model

  9. Self-Management • Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.

  10. Delivery System Design • The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.

  11. Decision Support • Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

  12. Clinical Information System • A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.

  13. Organization of Health Care • Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

  14. Community • To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

  15. Predicted Benefits of Control (Archimedes Model) Bailey JInt J Clin Pract 2005;59:1309-1316

  16. Joe Average Doc • “Not satisified” with HgbA1c >7, but…. • 68% reinforced diet and exercise • 27% augmented oral agents • 8% increased insulin

  17. Glargine 2 for 20 Rule • Start 10 units Daily (HS or AM) • Adjust weekly based on last 2 FPG values • Titration schedule • 2 units for each 20mg above 100mg • FPG 140  increase 4 units • FPG 200  Increase 10 units • NO increase in dose if BG < 72 or documented severe hypoglycemia

  18. BP Control Strategies • ACE, then diuretic, then ARB • If not a goal confirm • proper BP measurement • medication adherence • low sodium • Avoid EtOH > 2 oz /day, NSAID, decongestants, high dose estrogen

  19. Diabetic Nephropathy aka microalbuminura

  20. Preserving Renal FunctionLevel I recommendations • Systolic BP < 120mmHg • Maximum recommended ACE dose • Maximum recommended ARB dose • ACE plus ARB • Avoid dihydropyridine CCBs • Use beta blockers (BB) • preferred over DHCCB

  21. Preserving Renal FunctionLevel II recommendations • Glycemic control (HgbA1c < 7) • Stop smoking • Statin to achieve LDL < 100, or <70 • Aspirin • Limit sodium to 2-3 grams/day • Chicken instead of red meat?

  22. ACE worries • OK if creatinine > 3 mg/dl • Serum creatinine rises up to 50% OK if no further increase Hebert LA Kidney Int 2001;59:1211-1226

  23. Safety of ACE + ARB • Only decrease BP 4.5/2.5 mmHg • Small increase in K+ • Slight decrease in GFR • Proteinuria improves

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