Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes planned visits let patients become active participants in managing their diabetes. Patients set goals with their providers on what actions they will take to improve their health and manage their condition.

Diabetes Planned Visit

Overview

Ultimately, it is important to control blood pressure, blood glucose and lipids, but the patient is in control of all daily decisions and actions required to reach these goals.

Success in managing diabetes requires patients to take control of the illness, set meaningful self-management goals, and become competent in diabetes management.

Traditional education, handouts, and cajoling do not promote patient competence. The greatest success has occurred when patients are encouraged to set the agenda of the visit and coached in setting attainable and meaningful self-management goals. Thus, the essential components of a planned visit for clinicians are to address the concerns of the patient and then to partner with the patient to create a self-management goal. If this process takes the entire 30 minutes of the visit time, the patient should receive additional appointments to address issues such as getting glucose, blood pressure, and lipids to goal and completing health maintenance.

Is the patient ready for a diabetes planned visit?

Determine if the patient is ready for diabetes planned visit or has another more pressing need.

If the patient is not ready for a diabetes planned visit, use regular a progress note and re-schedule the diabetes planned visit.

If the patient is ready for a diabetes planned visit:

Begin with Pre-Visit Questionnaire

Scan the pre-visit questionnaire for serious symptoms (e.g., chest pain, stroke/transient ischemic attack symptoms). Prioritize evaluation of potentially life- or limb-threatening symptoms.

If there are no serious symptoms, record on the progress note the patient's answers to the following pre-visit questionnaire questions:

• What is the most important thing you hoped to get from this visit?
• What concerns you most about your diabetes?

Discuss and clarify the answers to these questions and address the patient's concerns.

Review progress on previous self-management goal

Ask "At the last visit, you planned to ... How did that go?" Explore the patient's insight into either "success" or "failure."

Review new Self-Management Goal Sheet

If no goal is recorded:

• Review with the patient the importance and concept of self management.
• Use the Self-Management Goal Sheet try to work with patient to create a meaningful self-management goal.
  • The goal should be an attainable small step to ensure success because effective self management is more likely with cumulative small successes.
• Review side two of the Self-Management Goal Sheet and review and discuss barriers and coping strategies.
• Revise self-management goal, if needed, and give it to the patient to take home and use as a guide.
• Record the new self-management goal on the front side of the diabetes planned visit progress note.

Tip: If goal is related to weight, diet, or glucose control, consider a referral to a dietician for help with setting dietary self-management goals.

Pre-Visit Questionnaire

• Review and confirm the patient's medication list. Update the green continuity sheet as needed.

• Review, explore, and record pertinent "positives" on diabetes planned visit progress note.

  If depression screening is positive, investigate and have the patient help prioritize. (Untreated depression and stress makes self management more difficult.)

  If not suicidal or homicidal, consider:

  • Scheduling a medical evaluation as appropriate.
  • Having the patient complete PHQ-9 Depression scale.
  • Scheduling a follow up for depression discussion.

• Review educational needs recorded on the pre-visit questionnaire.

  Pull educational handouts from the notebook and review then or near the end of the visit.

Physical Exam

• Re-check blood pressure.Consider intensification of regimen if the patient is not at goal (systolic < 130, diastolic < 70). (Use Nursing Blood Pressure Titration Protocol)
• Check heart and lungs.

• Examine feet.

  Note deformities, calluses, skin breaks, vascular status, and any fungal infection. Ask the patient to show how he or she checks the feet and tell you what he or she is looking for. Follow up by asking the patient what he or she would do if redness, swelling, broken skin, or an ulcer were present.

• Perform and record monofilament if not done within 1 year. Monofilament is not necessary if neuropathy is already confirmed.

Diabetes Report Card

• Review and explain the Diabetes Report Card results.
• Fill out prescription for labs for medication monitoring for the next diabetes planned visit as appropriate. Fill out corresponding section on Diabetes Management Report Card.
• Agree on follow up. If blood pressure or glucose are not at goal, schedule more frequent, focused (15 minute) visits to get to goal. These do not need to be diabetes planned visits. Consider nurse blood pressure checks or blood pressure titration. Schedule the next diabetes planned visit in 3 to 4 months if blood pressure, glucose, and lipids are at goal. Write "Diabetes Planned Visit" on the return slip to ensure 30 minutes and lab date updates are scheduled.
• Confirm that health maintenance is up to date. If it is not up to date, give patient a Staying Healthy handout and either schedule or plan to discuss at next visit.

Close the Loop

Ask the patient:

• What they understand about how they are doing.
• New self-management goal.
• What will transpire before next visit.

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