1 ADVANCE for Executive Insight

DIABETES
The nursing case
management approach
has paid
off handsomely.
At each 3-month
assessment, at
least 60 percent of
the clients demonstrated
a statistically
significant
decrease in A1c
levels, and only 25
needed additional
improvements.
with cognitive impairment or depression,” explained
Kathleen Falk, MSC, FNP, assistant professor
at New York City College of Technology
and chairperson of the ADHC study.
“It’s important to identify how we can best use
our nursing resources to help them stay in the
community with support,” Falk emphasized. “To
control their A1c levels is a very significant accomplishment.”
Easy as A-B-C
A structured care plan established the foundation
for individualized diabetes management.
“While a nurse could easily become sidetracked
by a hypertensive crisis that requires immediate
intervention, for example, the ABCs of
the care plan cues the nurse to look at the whole
picture after the crisis is resolved,” Falk said.
“People don’t generally die of diabetes — they
die from cardiovascular events. The care plan affirms
the value of nursing care coordination in
bringing together the diabetes team with a conference
call.”
Falk emphasized the importance of identifying
barriers to treatment, rather than labeling clients
as noncompliant. “We have an interdisciplinary
team for a reason, and a client’s barriers to care
can go unaddressed if the nurse doesn’t make
appropriate referrals,” she said. “We were able to
make headway by providing the nurses with education
about identifying and managing depression,
helping them understand that depression
presents differently in the elderly, or that culture
plays a role in how depression is expressed.
“Once we suspect depression, we further assess
with symptom rating scales and make referrals
to team disciplines such as social workers,
psychologists, and psychiatrists.”
The nursing case management approach has
paid off handsomely. At each 3-month assessment,
at least 60 percent of the clients demonstrated
a statistically significant decrease in A1c
levels, and only 25 needed additional improvements.
Data analysis demonstrated the effectiveness
for the group as a whole.
Population Management
Lory Dahlhauser, RN, CDE, a diabetes case manager
at Kaiser Permanente’s Stockton, CA medical
offices, described the three-level population management
model that her health maintenance organization
has adopted for members with diabetes.
“Level 1 members are newly diagnosed and attend
classes while their primary doctor manages
their diabetes,” she said. “Level 2 patients have
high A1c levels (above 8.5 percent) and receive
telephonic assistance from RN or RD care managers
for 6 months to a year to lower their A1c
levels, blood pressure and cholesterol.
“All members with type 1 diabetes, members
in renal failure and on dialysis, pregnant women,
children with diabetes, and members on insulin
pumps from our office are referred to me for
case management.”
When she receives a new referral, Dahlhauser
calls the member directly to set up an initial appointment.
“I establish right away that we’re going to work
together to keep them safe and their disease under
good control,” she said. “I personalize the approach
to target an A1c at a certain level, without
incidents of hypoglycemia.
“The rule of thumb is 7 percent, but members
who are older, have complications or experience
significant hypoglycemia, may be encouraged to
keep their A1c target closer to 8 percent.”
Dahlhauser makes good use of the Kaiser Permanente
website and the Internet for two-way
communication with members.
“I have a lot of patients who e-mail me, and
42 ADVANCE for Executive Insight