Gestational Diabetes: Center of Excellence Documents Processes

Transcription

1 Gestational Diabetes: Center of Excellence Documents Processes Chickasaw Nation Division of Health Dr. Judy Goforth Parker, Administrator CNDH Diabetes Care Center Melissa Vavricka Conaway, RD/LD, CDE Ada, Oklahoma

2 Gestational Diabetes: Center of Excellence Documents Processes

3 Gestational Diabetes: Center of Excellence Chickasaw Nation Gestational Diabetes Project Documents Processes A partnership between the Division of Diabetes Translation, CDC; National Association of Chronic Disease Directors (NACDD); and a Tribe to study data related to Gestational Diabetes and develop quality improvement strategies to improve diabetes data and patient care.

4 Gestational Diabetes: Center of Excellence Purpose Documents Processes Primary Outcome: To determine continuity of care during and post pregnancy: gestational screen, annual blood glucose screen and appropriate counseling/referrals of women with past gestational diabetes. To determine documentation of gestational diabetes screens conducted during pregnancies To determine documentation of annual care which includes a blood glucose screen To determine documentation of care delivered by the Diabetes Center Secondary Outcome: To determine if children of women with gestational diabetes are followed for diabetes risk.

5 Gestational Diabetes: Center of Excellence Documents Processes Process Randomized sample of all pregnant women. Time frame covered years 2000 through A total of 101 records were abstracted.

6 Gestational Diabetes: Center of Excellence Results Documents Processes Of the 101 records that were abstracted: 14 were found to have Gestational Diabetes 2 had pre-existing diagnosis ( 1 type 1, 1 type 2) 87.3% of women received a one hour GTT if visits occurred on or before the 24 weeks of pregnancy. 7.9% had a random blood glucose value if woman received prenatal care after the 24 weeks and before 36 weeks % of all pregnant women had appropriate blood glucose testing for Gestational Diabetes.

7 Gestational Diabetes: Center of Excellence Referral Process Women s Clinic Documents Processes Pre-conception counseling Automatic referral if DM or GDM history Screening: Random blood sugar screening at first pre-natal visit If blood sugar is >105, patient does 1 hr GTT 1hr. 50 g GTT between weeks If result is then patient is asked to do a 3hr GTT If result is in the normal range (<130), but falls in the higher range and is at high risk, the pt repeats 1hr at weeks If result is >160 then patient is automatically referred to the GDM program.

8 Gestational Diabetes: Center of Excellence Documents Processes Gestational Diabetes Team Doug Busha, PA-C Deb Provence, RN, nurse manager Justin Fowler, LPN Melissa Vavricka-Conaway, RD/LD, CDE, CBE Shon McCage, MPH, CHES, CBE Lacy Mann, RDH Deanna Carpitche, MS

9 Gestational Diabetes: Center of Excellence Documents Processes GDM Team approach The one stop shopping: Medical Management The PA monitors the pt s diabetes and determines appropriate care and/or medication regime Education Nutrition Exercise Breastfeeding Glucometer Instruction Insulin instruction (if needed) Dental Hygiene (exam, cleaning, & education) Behavioral Health Counseling (depression & domestic violence screening

10 Gestational Diabetes: Center of Excellence Documents Processes Summary The Women s clinic does a good job with gestational diabetes screenings. The Diabetes Care Center meets all standards of the Indian Health Services Best Practices for comprehensive gestational diabetes management. Missed Opportunities At 6 week post-partum check, women were not checked for blood glucose according to protocol. Women seen on annual family planning visits did not receive the screen as protocol states. 65% of women with Gestational Diabetes had a post-partum visit but no counseling of risk of diabetes was documented. No documentation of weight maintenance or weight loss.

11 Gestational Diabetes: Partnerships for Improving Care Chickasaw Nation Division of Health Dr. Judy Goforth Parker, Administrator CNDH Diabetes Care Center Shon McCage, MPH, CHES Ada, Oklahoma

12 Gestational Diabetes: Partnerships for Improving Care Based upon the results of the Chickasaw Nation Gestational Diabetes Collaborative Project, issues regarding quality improvement were discovered. The GDM team came up with some strategies and solutions to improve patient care.

13 Gestational Diabetes: Partnerships for Improving Care Quality Improvement Issues Post-partum visits (current rate is 65%) Post-partum diabetes screening Few women who had GDM return for annual family planning visits and/or the recommended annual screen. Women who have had GDM do not maintain their healthy lifestyle after delivery. Behavioral health services added to the GDM team.

14 Gestational Diabetes: Partnerships for Post-partum visits (current rate is 65%) Potential Strategies Improving Care *Women are given a post-partum visit appointment when discharged, will also try to make appointment with GDM team on the same day. *Working on improving process for scheduling appointments, OB and /or women s clinic to notify GDM team of delivery and date of post-partum visit. Work with Information Technology (IT) to develop a pop-up reminder on the EHR (electronic health record) to do diabetes screenings at the post-partum visit and annual visits. Explore possibility of a case manager Develop a referral system with other tribes to improve communication and feedback on post-partum care.

15 Gestational Diabetes: Partnerships for Improving Care Post-partum diabetes screening Potential Strategies *Staff recommended utilizing HgA1c as the screening tool, verses the 75 gm 2 hr GTT, which is a major barrier for followup. Exploring the HgA1c as the potential screen and standard of care and develop new policy and procedures for Chickasaw Nation. * Women s clinic providers are currently using the HgA1c at 6 week post-partum if pt was on insulin.

16 Gestational Diabetes: Partnerships for Improving Care Recommended Annual Screening Potential Solutions Work with Information Technology (IT) to develop a popup reminder on the EHR (electronic health record) to do diabetes screenings. Explore development of a recall system. Explore case management assisting with follow-up of women with GDM.

17 Gestational Diabetes: Partnerships for Improving Care Healthy Lifestyle Maintenance Potential Strategies Chickasaw Nation is one of 36 SDPI Diabetes Prevention grantees Uses the DPP curriculum Goal is to lose 7% body weight and exercise 150 minutes per week Pt s get pre and post class, and annual assessments. * Develop referral system with GDM team and diabetes prevention program After post-partum visit (women s clinic), pt will be referred to talk to lifestyle coaches of the diabetes prevention program.

18 Gestational Diabetes: Partnerships for Behavioral health services Improving Care A behavioral health counselor was added to the GDM team Depression screening Domestic violence screening If positive screening result, the counselor schedules appointments for follow up Women s clinic also increased depression screening Every trimester

19 Gestational Diabetes: Partnerships for Improving Care Future possibilities for year 3 activities Determine % of women with GDM that breastfeed compared to women without GDM, and the duration as a means to prevent obesity in woman and child. Develop a sampling process for abstracting records of children whose mother had GDM. Analyze results for quality improvement strategies.

20 Gestational Diabetes: Partnerships for Improving Care Questions