Support Staff Education for Diabetes Management

1. Support Staff Education for Diabetes Management Introduction Module 1: Diabetes Overview Module 2: Foot Care Competency Module 3: Glucose Monitor Competency Module 4: Order Entry / Standing Orders Appendix

2. NavMed Policy 06-011 To ensure effective care of diabetic patients, improve health outcomes and reduce cost within Navy Medicine. Standards: ID enrolled patients diagnosed with Diabetes (Pop Health Navigator) Implement CPG (clinical practice guidelines) Re-engineer disease management

3. Standards.. (cont) Train all members of the healthcare team on their roles and responsibilities. Conduct initial and ongoing training on basic skill competencies for team members. Provide comprehensive Patient Education Maintain Metrics Maintain a Diabetes Champion Toolkit

4. Questions? What are Clinical Practice Guidelines (CPGs)? Why do we need them? How are CPGs going to improve patient care? How will they affect my current responsibilities? What can I do to help?

5. Clinical Practice Guidelines ���systematically developed statements to assist provider and patient decisions about appropriate health care services for specific clinical circumstances.� Institute of Medicine (1992)

6. Why do we need them? Decrease variation in practice Care is based on research Increase appropriateness of care Decrease errors in healthcare

7. CPGs (cont.) Diagnosis, education, preventive screenings, risk reduction, and pharmaceutical treatment of diabetic complications occurs mostly in outpatient primary care settings. CPGs encompass the critical factors in diabetic patient care management: Glycemic control Foot and Eye evaluations ID and treatment of complications (HTN, hyperlipidemia, renal disease) It also incorporates flexible use of referrals: Diabetic Educator, Optometry, Ophthalmology, Podiatry, Nephrology, Endocrinology

8. How will they improve patient care? Evidence-based practice Provides a way to measure outcomes (metrics) Did what was suppose to happen really happen? Are we meeting our performance standards?

9. These are the outcome measures for diabetes. Was a HgbA1C done every year? Was a dilated eye exam done every year? Was an annual foot exam done? Was an annual urine test done to check for protein? Was an annual lipid profile done? Was a blood pressure done at least once a year? In this slide, less than 10% of patients with diabetes were screened microscopic kidney changes which can show up as protein in the urine.These are the outcome measures for diabetes. Was a HgbA1C done every year? Was a dilated eye exam done every year? Was an annual foot exam done? Was an annual urine test done to check for protein? Was an annual lipid profile done? Was a blood pressure done at least once a year? In this slide, less than 10% of patients with diabetes were screened microscopic kidney changes which can show up as protein in the urine.

10. CPG Population Level Metrics A1c Lipids Microalbumin Dilated eye exams Comprehensive foot exams BP<130/80 mm Hg Screened tobacco use Evidence-based Practice

11. What will you have to do? Become educated to the use of CPGs. Keep informed as the program progresses: new forms, new data entry requirements, etc. Follow the guidelines for care at each level: lab, exams, patient teaching, etc. Remain current in CPGs. Inform patients of available resources and updates.

12. Questions?

13. Staff Education Module 1 Key Elements in the Care of Patients with Diabetes

14. Learning Objectives: Upon completion of this module the learner will be able to: Distinguish between Type I, Type 2 and Gestational Diabetes. Identify characteristics of hypoglycemia and hyperglycemia. Identify current guidelines for diabetes care, goals of therapy and treatment guidelines. Identify the roles and responsibilities of staff in the management of the diabetic patient. Utilize assessment tools in the assessment of the diabetic patient. Implement diabetes education as an integral component of the patient�s self-management plan. Identify the need for referrals and specialty follow up.

15. What is Diabetes? Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone produced by the pancreas. Insulin is essential for the utilization of glucose (fuel) for cellular metabolism as well as protein and fat metabolism. Glucose is the fuel our body needs to function properly. We get glucose from the foods we eat. Without insulin, the body can not use glucose, plasma glucose levels rise (normal BS 70-110mm/dl) and glycosuria (glucose in the urine) results.

16. Both genetics and environmental factors such as obesity and lack of exercise play a role in the development of diabetes. Types of diabetes: Type 1, Type 2, and Gestational Pre-diabetes is a condition in which blood glucose levels are higher than normal but are not high enough to be diagnostic of diabetes.

17. Type 1 Diabetes Formerly called juvenile diabetes, is usually diagnosed in childhood / young adulthood. The beta cells of the pancreas no longer produce enough insulin. It may be an auto-immune disorder or idiopathic (no known cause). Treatment includes injectable insulin, or insulin pump, diet modifications, exercise, controlling BP and cholesterol.

18. Type 2 Diabetes Formerly called adult onset or Non Insulin Dependent Diabetes Mellitus (NIDDM). Most common form of the disease. Can develop at any age, even childhood. Unlike Type 1, the pancreas still produces insulin, but it either is not enough or the cells are resistant to it, and don�t respond effectively. Risk Factors: heredity, obesity, and inactive lifestyle Treatment: Medication, diet modifications, exercise, weight loss, ASA, controlling BP and cholesterol.

19. Gestational Diabetes Any degree of glucose intolerance with onset during pregnancy. Due to hormonal changes or a shortage of insulin. Risk Factors: overweight / obesity, parent or sibling with diabetes, inactivity, hypertension, elevated cholesterol or triglycerides, elevated glucose in past. Usually resolves after delivery. Increased risk of developing Type 2 diabetes later in life.

20. Symptoms (characteristics) of Diabetes Frequent thirst Frequent urination Feeling hungry Losing weight without dieting Slow wound healing Dry, itchy skin Numbness, tingling in feet Blurry eyesight

21. How is Diabetes Diagnosed? There are several ways to diagnose diabetes. 1. Symptoms of diabetes and plasma glucose >200mg/dl. 2. Fasting Plasma Glucose (FPG) >126 mg/dl on 2 separate occasions. 3. 2 hr plasma glucose (PG) >200mg/dl after 75gms of oral glucose.

22. Hyperglycemia (glucose>160 some use 275 mm/dl) Due to too much exercise, not taking diabetes medications, eating too much, medication interactions, stress, illness. S/sx: thirst, blurred vision, frequent urination, fatigue, n/v, muscle cramps, ketoacidosis TX: diabetic medications, fluids, follow meal plan, exercise plan

23. Hypoglycemia (Blood glucose 70 mg/dl or less) Due to skipping or delaying meals or snacks, increasing activity, or increasing insulin / diabetes medications Symptoms: Shakiness Sweating Rapid heart rate Hunger Irritability Lightheadedness May progress to: inability to concentrate, confusion, slurred speech, blurred vision, fatigue. If glucose continues to drop, seizures & loss of consciousness can occur

24. Know the difference Hypoglycemia: low blood glucose: give glucose Hyperglycemia: high blood glucose: give insulin S/Sx very similar, treatment very different

25. Treatment of Hypoglycemia 15 grams of quick carbohydrate (CHO), (airheads) Recheck glucose in 10-15 min If < 70 repeat 15 grams CHO

26. Chronic Complications of Diabetes (related to prolonged hyperglycemia) Macrovascular Cerebrovascular Disease Coronary Artery Disease Microvascular Retinopathy Nephropathy Peripheral Neuropathy

27. General Overview of Complications Cerebrovascular Disease:hypertension,elevated lipids,and uncontrolled glucose increase risk of stroke and transient ischemic attack. Coronary Artery Disease: atherosclerosis and vessel damage increase risk of heart attack. Retinopathy: appearance of hemorrhages and damage to the retina, leads to blurred vision, �floaters�, flashing lights. Nephropathy: thickening of the glomerular membranes and renal vessel sclerosis leads to diminished renal function. Peripheral Neuropathy: decreased sensitivity of the feet to touch,vibration,and temperature.

28. Desired Outcomes for the Patient with Diabetes (metrics) Blood glucose Level: 70-100 mg/dl A1c: <7% Blood Pressure: <130/80 Urine microalbumin: <30 mg/24hr Cholesterol: <200 mg/dl Triglycerides: <150 mg/dl LDL-cholesterol: <100 mg/dl HDL-cholesterol: >45 mg/dl

29. Goals of Therapy The patient will achieve and maintain a: Healthy weight. Good quality of life Exercise program Management plan acceptable to the patient and health care team.

30. Medications Oral Agents: for patients producing insulin Insulin Preparations: for patients unable to produce insulin or not producing enough. Type 1 diabetics require insulin. Many with Type 2 require insulin. (competency check) Insulin pumps: insulin delivered under the skin via needle Some patients use a combination of oral preparations, some use oral meds with insulin, some use insulin alone. See VA/DoD CPG Table G4, G5, G6

31. Glucose Monitoring NHCH uses the Precision Xtra Glucose Monitor. (competency check) Please refer to the Quick Reference Guide for glucose and ketone calibration and testing. Instructional Video (Module 3) Demonstration / Practice (Module 3) Familiarize self with �Living Well with Diabetes, �A guide for Staying Healthy�

32. Diet Focus on lifestyle changes not just weight loss. CHO: 60-70% carbs and monounsaturated fat. Protein: 15-20% diet FAT: 10% saturated fat, 10% polyunsaturated fat Fiber: 20-35 grams Limit alcohol (1 drink /day (f) , 2 drinks/day (m) Refer to Diabetes Class Resources: �Survival Skills �for the Person with Diabetes�, �Food Pyramid�, �Your Guide to diabetes..�, �Carb Counting�

33. Exercise Moderate sustained exercise may help regulate glucose. Before starting an exercise program, patients over 35 with diabetes should have a physical exam. Patients should be instructed in proper shoes/foot care Instructed in effects of exercise and insulin need, CHO intake See guideline for �Making Food Adjustments for Exercise� handout.

34. Sick Day Management Common illness, such as the flu or a cold, can cause serious problems for the person with diabetes. Education includes: Medication dosage variation Monitor blood glucose more often (q4hrs) Increase liquids, especially with a fever May need to check urine for ketones See �Survival Skills�for the Person with diabetes� and �Your Guide to Diabetes, Type 1 and 2�

35. Roles of the Healthcare Team: Staff Diabetic education is key to a successful diabetes management plan. The overall plan should include: Smoking cessation plan (if applicable) Exercise plan Glycemic control (ideally A1c <7%) Lipid management Blood pressure management

36. Clinic visit Physical examination includes: Blood pressure Foot exams Weight Eye exam with dilation (annually) Lipid profile Patient Education Medication Glucose monitoring Diet / exercise Foot care When to seek treatment Sick day management

37. While diabetes is a serious, common, and costly disease, it is controllable. There are many things people with diabetes can do to control symptoms and prevent complications. That is why patient education is crucial to successful diabetes management. And that is where YOU come in.

38. The staff�s role in patient education Provide culturally competent care: keep in mind the patient�s cultural, religious, educational, and developmental needs. Be respectful. Be prepared: have all that you need. Ask for feedback from the patient. Did they understand?

39. Staff role (cont) Give handouts / resource materials as reinforcers. Use referrals ie: Diabetes Education Classes Podiatry Fitness Trainers

40. Access to information Kiosk www.tricareonline.com Written patient education materials: pamphlets, books, videos, charts, handouts, etc. CPG

41. Diabetes Control Network(pfizer) Disease Management Program: helps patients face the challenges in managing their diabetes. Patient Education Materials Monthly Newsletters Daily Journals Scorecards/checklists to bring to clinic Rewards (pedometer, T-shirts) Tools for the Provider

42. Staff Education Module 2 Diabetic Foot Care Competency

43. FOOT CARE COMPETENCY TRAINING FOR SUPPORT PERSONNEL VICKIE R. DRIVER, DPM, MS, FACFAS CHIEF, LIMB PRESERVATION SERVICE DEPARTMENT OF ORTHOPAEDICS MADIGAN ARMY MEDICAL CENTER March, 2004 (modified May 05) Before we start, does anyone have an idea of what CPGs are? (Get some feedback from class). What do you think some reasons might be for using CPGs in military hospitals? Before we start, does anyone have an idea of what CPGs are? (Get some feedback from class). What do you think some reasons might be for using CPGs in military hospitals?

44. Foot Care Competency Guideline Introduction The purpose of this training is to provide support personnel with a specialized, three tier program of instruction in providing foot care to patients with diabetes and assisting health care providers who care for them.

45. Foot Care Competency Guideline The training advances with a higher level of specialized and detailed training as you move from basic to intermediate to advanced foot care. Training includes formal lectures and hands on experience.

46. Foot Care Competency Guidelines Developed in a three tier program for foot care Basic Intermediate Advanced Note pages Clinical supervision

47. Foot Care Competency Guidelines Evaluations Direct observed performance Competency training check list

48. Foot Care Competency Guidelines Management Plan Self-management education Diagnostic studies if required Foot wear recommendations, orthotic prescription if required Nail, skin and ulcer care Follow-up dates Low Risk � 1 year High Risk � 4 weeks

49. FOOT CARE COMPETENCY The purpose of this teaching plan is to provide clinical and didactic understanding to providers that directly correlate to the foot care competency level achieved.

50. Foot Care Competencies More complex foot care skills are designated medical acts and licensed nursing personnel are advised to follow the guidance of the facility�s locally approved foot care protocols Facility privileges are required for advanced foot care skills

51. Foot Risk CategoriesThe level of foot care skills depends on the foot risk category of the patient and on the type of foot exam being done. Low Risk Category Intact protective sensation No history of foot ulcer No history of amputation Intact pulses Absence of foot deformities

52. Foot Care Competencies A visual foot exam is recommended at every visit with patients in the low risk category. A more comprehensive foot assessment including foot structure, skin integrity, vascular status and protective sensation is performed annually with patients considered to be low risk and as indicated with patients in the high risk category.

53. BASIC FOOT CARE WHY IS BASIC FOOT CARE IMPORTANT? There were an estimated 86,000 diabetes-related lower extremity amputations (LEA) in 2002 (1) Approximately 85% of LEAs are preceded by foot ulcers (2,3) The leading cause of amputations is diabetes

54. Basic Foot Care The goal of basic foot care is to prepare patients in the low risk category for a visual or more thorough examination.

55. Basic Foot Care�Limb at Risk� Factors A history of diabetic foot ulcer (DFU) or partial foot/toe amputation History of Charcot Foot Foot deformity Neuropathy Peripheral vascular disease (PVD) Compromised skin integrity Compromised nutritional status Sacral decubitus ulcer Lower extremity cellulitis Poor glycemic control, A1C > 8

56. Basic Foot Care�Limb at Risk� Factors Rheumatoid with difficulty ambulating Neuro-muscular disease, e.g. Spina Bifida Auto-immune diseases End stage renal disease Scleraderma Post burn Post-surgical sites of lower extremity, e.g. venous harvest site Deep vein thrombosis (DVT) history Symptoms of claudication

57. Basic Foot CarePatient History Cover wide range of patient information including Walking difficulties Shoe problems Pain Social issues (e.g. smoking, alcohol use) Age Sex Weight Ethnicity Glycosylated hemoglobin level

58. Basic Foot CareFoot Evaluation Protective sensation Musculoskeletal deformities Vascular status Skin and nail condition Pedal pulses Sensory and motor foot exam Gait evaluation

59. Basic Foot CareSkin Assessment Why is checking the skin so important? First line of defense against infection Provides sensory perception It is important to look at the skin for any redness, swelling, sores, corns, calluses, ulcers, fissures and drainage The most important skill is having the patient remove their shoes and socks

60. Basic Foot CareSkin Assessment Why is skin temperature important? Skin temperature ranges from cool to warm to the touch At best, touching is a rough estimate of skin temperature but look for bilateral symmetry of skin temperature Environmental conditions will affect skin temperature A variance of 2-3 degrees may indicate infection and/or fracture Using an Infrared Temperature Scanner for accurate assessment of temperature is invaluable

61. Basic Foot CarePeripheral Vascular Assessment Skin Does the skin look pink or dusky? Is there hair on the toes?* Are the toenails brittle and thick?* * May indicate poor circulation. Brittle and thick toenails can be seen as a normal part of aging. Yellow discoloration occurs with fungal infections.

62. Basic Foot CarePeripheral Vascular Assessment Pulses should be palpated but can be difficult to find. Palpate the dorsalis pedis (Medial side of dorsum of foot with foot slightly dorsiflexed) Palpate the posterior tibialis (Behind and slightly inferior to medial malleolus of ankle)

63. Basic Foot CareVascular Assessment (cont.) Notify the clinic nurse or PCM if pulses cannot be felt. Nurse or PCM may then use a Doppler to assess pedal pulses Using the Doppler, note whether pulses are monophasic, biphasic or triphasic

64. Basic Foot CareNeurological Assessment The monofilament exam is done using a 5.07/10gm monofilament. Hold the monofilament by the handle Use a smooth motion to touch the skin on the foot for 1-2 seconds Touch along side of and not directly on any ulcer, callous or scar

65. Basic Foot CareNeurological Assessment (cont.) Touch the foot to make the monofilament bend. Touch only once and do not drag the monofilament along the skin. Repeat the test if patient does not feel the monofilament.

66. Basic Foot CareNeurological Assessment Place a (+) in the circle if the patient can feel the monofilament at that site and a (-) if the patient cannot feel the filament at that site. (see chart)

67. Basic Foot CareNeurological Assessment Notify the nurse or PCM if the patient cannot feel the filament at any site. Give patients a basic instruction sheet which describes daily inspection of feet, proper hygiene practices, exercise, proper footwear, review of lifestyle habits such as tobacco cessation and when to report problems. Report any abnormal findings to the nurse or PCM

68. Basic Foot CarePatient Education Examples of basic foot instruction can be found in the VA/DoD tool kit. Example can be found at: http://www.ndep.nih.gov/diabetes/pubs/feet_broch_Eng.pdf Notify nurse or PCM if patient has any concerns regarding proper foot care.

69. Intermediate Foot Care The goal of intermediate foot care is to assess patients more thoroughly for early detection of problems and to implement foot care maintenance and education.

70. Intermediate Foot Care:Skin, Nails and Foot Anatomy Skin Protect against infection Provide sensory perception Repair surface wounds Has three layers: epidermis, dermis and hypodermis Nails Epidermal cells converted to hard plates of keratin

71. Intermediate Foot CareSkin, Nails and Foot Anatomy Foot Tibiotalar joint consists of the articulation of the tibia, fibula and talus Protected by ligaments on the medial and lateral surfaces Tibiotalar joint permits flexion and extension Talocalcaneal (subtalar) joint and transverse tarsal joint permits pivot or rotation movement.

72. Intermediate Foot Care Conduct an assessment of the feet to include: History of Present Problem Any changes in the feet since last diabetes visit? Any changes in the skin of the feet such as dryness, itching, sores, ulcers, corns, calluses, swelling, redness, or drainage?

73. Intermediate Foot Care History of Present Problem Any leg pain or cramps? Does it occur with rest or activity? With elevation of legs? What makes it better or worse? Any burning in feet? Is it continuous, induced by activity? Any pain? Onset, location, duration, what makes it better or worse?

74. Intermediate Foot Care History of Present Problem cont. Any skin changes, cold skin, hair loss or pallor? Any history of injury or trauma? Any history of ulcers? Past Medical History Any past medical history of ulcers, changes in skin sensitivity?

75. Intermediate Foot Care Past Medical History (cont.) Any history of diminished sensitivity? Any systemic problems such as thyroid disorders or skin problems? History of chronic diseases (hypertension, coronary artery disease, thyroid?) Any history of skeletal deformities or congenital anomalies? Any surgeries?

76. Intermediate Foot Care Past Medical History Any change in activities of daily living or in the ability to walk? Family History Any familial hair loss or coloration patterns? Any family history of skin disorders? History of chronic diseases (diabetes, hypertension, hyperlipidemia, heart disease or thyroid disease?)

77. Intermediate Foot Care Family History (cont.) Any family history of weakness or gait disorders? Personal/Social History Skin care habits (kinds of soap and lotions used, home remedies) Skin self-examination Any difficulty trimming nails?

78. Intermediate Foot Care Personal/Social History cont. Any exposure to sun, chemicals? What type of work is done, physical demands involving the feet? Functional ability to walk, bath, dress, climb stairs, care for others, shop or fulfill work expectations? Any use of mood-altering drugs?

79. Intermediate Foot Care Personal/Social History cont. Tobacco use? What type, how often, cessation attempts? Alcohol use? What type, how often? Exercise? What type, how often, what intensity and for how long? Nutrition Type of diet Weight gain or loss

80. Intermediate Foot Care Personal/Social History (cont.) Any recent psychologic or physiologic stress? Sleep pattern?

81. Intermediate Foot Care Observe gait How does the patient walk, sit down, rise from sitting position, takes off coat, respond to directions? Is there any limping, shuffling, staggering or foot dragging? Observe for joint symmetry and alignment Inspection of the feet to include: Shoes for rough spots, foreign objects or tears

82. Intermediate Foot Care Inspection of the feet to include: (cont.) Soles of shoes for worn down heels >30% Socks or stockings for holes or pressure points Skin of legs and feet for sores, calluses, ulcers, lesions, redness, drainage, edema, or dryness (to include between the toes, heels and bottom of feet)

83. Intermediate Foot Care Inspection of the feet to include: cont. Toenails for length, thickness and fungal infection Feet and toes for deformities or bunions Amputation Palpation Palpate the right and left posterior tibialis and dorsalis pedis pulses

84. Intermediate Foot Care Palpation (cont.) Use Doppler to identify an arterial signal and measure ankle brachial index (ABI) Skin temperature Edema Nails for capillary refill time

85. Intermediate Foot Care Sensory Exam to include: DTRs Vibration Position sense of toes Monofilament exam See previous slide for instruction on monofilament exam

86. Intermediate Foot Care Interventions Hygiene Moisturizers What to use and what not to use Buffing and padding Lecture and demonstration Trimming and nail debridement Lecture and demonstration Use of rotary tool or electric grinder

87. Intermediate Foot Care Documentation Use of SF600 or AHLTA Patient Teaching Build on basic instruction sheet Educate in self-care and when to report problems Discuss lifestyle habits such as tobacco cessation

88. Intermediate Foot Care Follow-up/Referral Refer patient with abnormal findings to a foot care specialist if they are at risk for complications or functional impairments (see DM CPG for high risk foot) Refer for individual or comprehensive diabetes education

89. Advanced Foot Care The goal of advanced foot care is to provide prompt interventions for specific foot problems until the problem is resolved Clinical supervision of 120 hours or as determined by governing/hospital body Interventions governed by locally approved protocols Facility privileges required

90. Advanced Foot Care Must demonstrate has basic and intermediate foot care skills to include a comprehensive history Diabetes foot complications Pathophysiology of diabetes Pathophysiology of foot complications Corns, calluses and ingrown toenails PVD Infections Ulcers

91. Advanced Foot Care Principles of Infection Control Corns and Callous Debridement Wound Care Principles Wound Classification System Dressing and Dressing Changes Use of antibiotics and antifungals Topicals and Oral agents

92. Advanced Foot Care Anesthetic Administration Anesthetic symptoms, complications and contraindications Digital Blocks Understanding anatomy Protocols Therapy options Indications and contraindications Complications Post-procedure therapy plan

93. Advanced Foot Care Anesthetic Administration Oralets for administering treatments Debridement Biopsy Nail Removal

94. Advanced Foot Care Other issues related to the foot Understanding strains and sprains of the ankle Shoes* Socks* *What�s supportive and what�s not

95. Advanced Foot Care Diagnostic Studies X-rays Noninvasive vascular studies Bone scans Cultures Labs

96. Advanced Foot Care Documentation using SF600 or AHLTA Patient Education Specialty Referrals

97. References Center for Disease Control and Prevention (CDCP), National Center for Chronic Disease Prevention and Health Promotion. The Burden of Heart Disease, Stroke, Cancer, and Diabetes, United States. In: The Burden of Chronic Diseases and Their Risk Factors. National and State Perspectives 2002. http://www.cdc.gov/nccdphp/burdenbook2002/02_diabetes.htm Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13: 513-52, 1990. Larsson J, Agardh C, Apleqvist J, Stenstrom A: Long term prognosis after healed amputations in patients with diabetes. Clin Orthop 1998; 350:149-158.

98. For any MTF, clinic, or individual who is interested, copies of the guidelines, everything in the tool kit, ordering information, and general information relating to practice guidelines can be found on our practice guideline web page. For any MTF, clinic, or individual who is interested, copies of the guidelines, everything in the tool kit, ordering information, and general information relating to practice guidelines can be found on our practice guideline web page.

99. QUESTIONS? (Encourage staff to ask questions) (Encourage staff to ask questions)

100. Staff Education Module 3 Learning Objectives: upon completion of this training session which includes handouts, and training video, the learner will be able to: Complete the competency tasks and correctly use the Medisense Precision PCx glucose monitoring system. Instruct the patient in the use of the Medisense Precision PCx glucose monitoring system.

101. Glucometer Training Precision Xtra Instructional video Hands on demonstration

102. Staff Education Module 4 Order Entry Using Standing Orders

103. Learning Objectives Upon completion of this module, the learner will be able to: Determine the roles and responsibilities of the HM/LPN and clerical staff. Discuss phone call protocols and appropriate follow up. Determine patient needs according to clinic visit. Use standing order form to prepare patient for PCM visit. Verbalize key elements in the Care of Patients with diabetes.

104. Front line contact: Phone call protocols: What, When, Where and Who? What needs to be evaluated? When does the patient need to be evaluated? Where should the patient go first? Who does the patient need to be evaluated by?

105. Initial Visit following Diagnosis Comprehensive Patient Education Meds Importance of Diet, Exercise, Foot Care Tracking Blood Glucose When to call for advise / help Influenza Vaccine (in season)

106. Each Routine Primary Visit Visual foot Inspection ( especially if high risk patient) Tobacco Cessation and counseling/referral BP Self BGM results

107. Quarterly to annually A1c measurement and risk assessment If A1c is not on target: education reinforcement (diet, exercise, meds)

108. Annually Dilated eye exam (make appt for optometry) Microalbuminuria screening Lipid Profile (make appt for lab) Visual inspection, documented foot risk assessment and education Flu vaccine (in season) Pneumonia vaccine (if indicated)