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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?