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Effective Teamwork Strategies for Managing Diabetes Care at Yakama Healthy Heart Program

The Yakama Healthy Heart Program, led by Case Manager Robin John, RPh, CDE, offers comprehensive management for over 1100 active Type II diabetic patients. The program emphasizes collaboration among clinical pharmacists, nursing staff, nutritionists, and case managers to develop individualized care plans. Key components include medication management, education, monitoring vitals, and addressing barriers to care. By focusing on specific goals, follow-ups, and patient-directed visits, the program aims to empower patients in their diabetes management journey. Contact Robin John for more information.

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Effective Teamwork Strategies for Managing Diabetes Care at Yakama Healthy Heart Program

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  1. Teamwork You and Your Case Manager Robin John, RPh, CDE Yakama Healthy Heart Program Coordinator

  2. Case Management Team Members • Clinical Pharmacists • Pharmacy Technicians

  3. Screening • Providers • Nursing • Nutrition • DM Center • Pharmacy • Patient Registration • Currently over 1100 active DM patients at YIHS

  4. Who Qualifies for Program? • Type II Diabetics • Over 18 years old • Not Pregnant • Not on Dialysis or have End Stage Renal Disease • No Substance Abuse Issues that may interfere with treatment plan • Chemotherapy

  5. Define Your Role • Education • Medication Management • Monitoring • Referrals • Physical Assessments • Procedure for Acute Care • Contact Information • Develop rapport

  6. Duties of Case Manager • Identifying Data • Name • Address & Phone • Family Contact/Support Person • Date of Birth • Chart Number • Assessments • Care Plan/ Problem List

  7. CMV at Yakama • First Appointment – 1 hour • Forms, HIPPA, • Prior Knowledge • Motivation • Follow-up Appointments (usually ½ hour long) • Review Problems • Set goals, Review goals • Standards of Care • Frequency

  8. Case Management • Individual Case Management • Disease Management • Self Management Education

  9. Concerns, Questions, Reports • Patient Directed Visits • Plan for the “Controlled Patient” • Focus on 1-2 issues per Appointment • Set at least one SMART goal per Appointment • specific, measurable, attainable, realistic and timely • DOCUMENT AND REVISIT

  10. Individual Case Management • Patient Directed • Needs • How can we meet that need • Other team members • Barriers to Care • Visits • Problem Solving • Communication and F/U

  11. Daily Living • Family/ Psycho-Social Issues • Work • Child Care • Transportation

  12. Family Affair

  13. Stress Factors • Domestic violence • Death in the Family • Unemployed • Divorce • Child Care Issues

  14. Disease Management • Each Visit • Physical Assessment • Medication Management • Treatment Goals • Main focus is ABC’s • cont. the alphabet as CM evolves • Treatment Strategies • Quality Improvement

  15. Vital Signs • Weight • Height • Waist • Hips • Blood Pressure Goal: under 130/80

  16. Diabetes Report Card

  17. Standards of Care Reminders

  18. Reminders EHR, Flow Sheets, Tracking Log, Reminders

  19. Medications • Name of Medication • What it is for? • How it works • Side Effects • Adverse Reactions • Monitoring • Dose Adjustments • How do you take your medications • Allergies • Medication Alignment

  20. Medications

  21. Mammograms Colon Cancer Screening Exercise (DM Center) Foot Problems Dental Optometry Mammograms Colon Cancer Screening Exercise (DM Center) Foot Problems Dental Optometry Referrals

  22. Immunizations • Flu – yearly • Td – booster every 10 years • PPD • Pneumovax

  23. Foot Exams

  24. Lab Values • Blood Sugar A1C (My 100 Day Test) Goal: less than 7% . Cholesterol Every 6-12 months Goals: Total cholesterol <200 LDL (Bad Guy) <70 or 100 HDL (Good Guy) over 40 Triglycerides: under 150

  25. Monitoring and Labs

  26. Other Necessary Labs • Liver Function Tests • Kidney Function Tests • Urinalysis • Thyroid • Complete Blood Count • Drug Levels

  27. Team Approach • Referrals to • Dental • Optometry • Physical Therapy • Medical Provider • Nutritionist • Exercise Educator • Mental Health

  28. Documentation

  29. Improvement of Health • Education • Plans for medical emergency • Plans for extended trips • Referrals • Consultations • Safety Issues • Medication Refills

  30. Self-Management Education • AADE accreditation • Follow AADE Self Behavior Goals • SMART Goals • Document • Develop Plan • Follow-up

  31. Review Goals • Results? • Barriers? • Accomplished? • Incentive

  32. Acknowledge Achievements

  33. Activity Level • GOAL: 150 minutes / week -walking -dancing -housework -swimming -take the stairs -park farther away from destination

  34. Graphs for Progress

  35. Nutrition & Diet • Portion Sizes • Meat Choices Fish, Deer, Bison, Chicken, Turkey, Lean Beef • Healthy Alternatives Grilled, Baked, Broiled . Processed Foods White Bread, Pasta, Flour

  36. Message of the Month

  37. TRACKING

  38. Staying Sustainable

  39. ANY QUESTIONS?

  40. Thank You Robin.John@ihs.gov Yakama Healthy Heart Program 509-865-2102 ext 299 or 509-865-1715

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