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

9. The Chronic Care Model

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

17. Predicted Benefits of Control (A rchimedes Model) HgbA1c < 7 Within 6 mosWithin 24 mos Proteinuria  52%  15% ESRD  44%  16% Eye surgery  73%  41% Blindness  73%  47% Bailey JInt J Clin Pract 2005;59:1309-1316

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

19. 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

20. 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

21. Diabetic Nephropathy aka microalbuminura

22. Preserving Renal Function Level 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

23. Preserving Renal Function Level 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?

24. 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

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