Shelley Thorkelson CNM MSN CDE

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Diabetes in Pregnancy Program
Project Overview
Case Tracking Strategies Using RPMS , CMS, DMS
and Hard Copy

• Shelley Thorkelson CNM MSN CDE
• Diabetes in Pregnancy Case Manager
• Northern Navajo Medical Center
• Shiprock, New Mexico Service Unit

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Northern Navajo Medical Center Shiprock, New
Mexico
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DM Preg Project Goals

• Rapid identification of new cases
• Tracking daily appointed cases in clinics
• Monitoring case status and changes
• Supplying clinical and educational visits
• Tracking interventions outcomes
• Statistical review
• Communication of findings and recommendations to
  clinical and support staff

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Program Focus

• Reduction of perinatal morbidity mortality
  statistics
• Increase Diabetes education awareness for each
  family served
• Compile a usable data base for future studies.

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Finding the Sweet Moms

• Rapid ID of New or Potential Cases
• RPMS Bulletins QMAN Searches
• Daily Mailman Bulletins generated from ICD-9
  Codes 648.03, 683.83, and 648.93
• Weekly Q-Man Queries of abnormal GTTs both 1hour
  and 3 hour results.
• Monthly lab report on all 2 hr GTTs done (this
  lab test in not currently in the Q-Man List of
  tests for potential query).
• Allows for FU on mothers who are now pre-diabetic
  or diabetic postpartum
• Male patients from this list are assigned to
  appropriate case managers for follow-up.

-for more info Shelley Thorkelson CNM MSN
shelley.thorkelson_at_ihs.gov
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Sweet Mom Search cont.,

• Appointments DMS System DA Function
• Registers are queried for appointed patients in
  facility clinics daily at 0800
• Patients with pending GTTs and not on a register
  are tracked for appointments in the SCH section
  of RPMS

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Case Data Tracking

• Enter Case into appropriate RPMS Register and
  onto hard copy Excel List
• CHO Intolerant (1 ABN Value on 3 hr GTT)
• GDM (2 or more ABN Values on GTT)
• PGDM (Pregestational Type 2 DM)
• ABN 1 HR GTT FU (needs 3 hr GTT)
• Establish DM Pregnancy Program Case Management
  Flowsheet
• Form that tracks case progress, education topics
  covered, visit notes, etc.

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RPMS Registers 101

• Created within the CMS System
• Only the creator can add users/change parameters
• Name must include the word DIABETES to come up in
  the DMS menu
• DECC Diabetes
• DECC Pregestational Diabetes
• DECC Gestational Diabetes
• DECC CHO/INTOL Diabetes
• OFFSPRNG Diabetes Mom
• ABN 1 HR Diabetes Screen FU
• Registers Value
• Query of these special populations assist follow
  up care plans
• Are updated automatically when coders enter
  values/codes for complications, etc.
• Can be audited for quick status on SOC

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Excel Hard Copy Rosters

• Why?
• No simple current way within RPMS to have a one
  page running list of all cases and data values to
  take with you on rounds, etc.
• Column Headings
• Plan ahead what data do you want to track?
• Name/MR/PCP/EDC/50gm/FBS/1HR/2HR/3HR/
  1TA1c/MNT/CM/Meter/Log ck/PO/Insulin/DEL
  Date/Type/Sex/MR/BW/Category/PP Appt/2 HR
  Value/FU Notes/BF/BCM/FU Plan, etc.

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Spread Sheet Template

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Case Management Flowsheet

• Why yet another form?
• Single best way found so far to have the entire
  case status in one spot
• All topics discussed noted
• All referrals given are tracked
• All prenatal SOC parameters tracked
• Case Notes and Plans documented for quick recall
• Value of double charting assists in continuity
  of care and plan adherence
• Eliminates endless searching thru PCCs for info

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Sample Flowsheet Form
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Tracking Nuts Bolts

• Process Recipe
• Check DMS DA Register Appointment Lists Q1-4
  days
• Review SOC Audit leave message for PCP
• Check RPMS Mailman Q 1-4 days save s not on
  the list
• Review HS to determine if bulletin trigger
  accurate
• New Case Enter into Excel, RPMS Register and
  start a Flowsheet
• Enter next appt in daily calendar leave send
  her over note.
• Active Cases Update flowsheet at each
  visit/chart pull/after delivery/end of year for
  stats.
• Updates Review delivery log prn for birth data
• Follow-up PP note 6 wk PP appt in RPMS SCH
  enter on daily calendar leave reminder needs 2
  HR GTT for PCP.
• Review open pp cases periodically for lab values
• End of year pull all mom baby charts
  update/add data for accurate stats.

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Value of the Portable Office

• Case Files Available
• Teaching Materials
• Supplies
• Instant Documentation
• Mobility
• Easy access for clients
• Continuity
• Organization

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NNMC 2005 DM Pregnancy Statistics

• Total Cases 105
• 13.5 of all pregnancies
• CHO 17
• GDM 66
• PGDM2 22
• Maternal Birth Weights
• 46 Known
• SGA 35
• AGA 48
• LGA 17
• Mean Pre-preg BMI 32
• First Trimester A1c 7 - 45
• HTN Co-morbidity 22

• Antenatal Testing 60
• Kick Counting Documented 34
• SVD Rate 60
• Complication Rate 55
• Oligo/Poly/Fetal/Mec/PPH
• Birth Weights
• AGA 52
• SGA 5
• LGA 43
• Macrosomia 34
• Level 2 Nursery Care 17
• Hypoglycemia 20
• Jaundice 28
• Breastfeeding Rate 74
• Average duration 11 weeks

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NNMC 2006 DM Pregnancy Statistics

• Total Cases 101
• 14 of all pregnancies
• CHO 17
• GDM 58
• PGDM2 26
• Maternal Birth Weights
• 32 Known
• SGA 44
• AGA 15
• LGA 41
• Mean Pre-preg BMI 32
• First Trimester A1c 7 - 42
• HTN Co-morbidity 46

• Antenatal Testing 63
• Kick Counting Documented 88
• SVD Rate 52
• Complication Rate 58
• Oligo/Poly/Fetal/Mec/PPH
• Birth Weights
• AGA 55
• SGA 4
• LGA 41
• Macrosomia 47
• Level 2 Nursery Care 34
• Hypoglycemia 18
• Jaundice 24
• Breastfeeding Rate 54
• Average duration 9 weeks

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Comparison 2004 2006 Stats

• Improved Areas
• h visits to CM/RD
• Time from Dx to DM Care Services
• h Sweet Success Log Eval visits
• h using meters
• h antenatal testing for PGDM2 women
• h AGA rate for GDMs
• h PP visits for GDMs
• h PP GTTs done for GDMs

• Focus Areas
• MNT visits for GDMs
• Time from 1 to 3 HR GTTs
• US Eval rates
• Hyperglycemia in clinic visit no trigger to
  DECC
• Eye exams for PGDM2
• Antenatal testing for GDMs
• Big babies are even bigger
• Birth wts for PGDM2
• PP DNKA rate/FU GTT
• Breastfeeding Rate

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DM Pregnancy Program Overview

• Questions?

Need More Information ??contact me Shelley
Thorkelson CNM MSN shelley.thorkelson_at_ihs.gov