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Diabetes Disease Management

Overview

The Diabetes Disease Management Program helps the patient and their family understand and manage the diabetic disease. The nurse utilizes other members of the homecare team, including the social worker, nutritionist, and rehabilitation staff. Through a comprehensive program the patient can learn to control their diabetes, and lead a full and active life. Care planning is individualized, and establishes a self-care plan that works for the patient and their family. All care is provided under the direction of the physician.

Components

  • Education about the diabetic disease process, including causes and symptoms, and treatment overview.
  • Blood sugar monitoring and home glucometer instruction.
  • Initiation of in-home lab work as ordered by the physician to look at determinants of diabetic compliance, including the hemoglobin A-1-C.
  • Meal planning, including general guidelines, common questions, food lists, and label reading.
  • Education about the role of exercise in diabetic management.
  • Teaching about diabetic medications and self-care skills related to preparing and administering an insulin injection.
  • Management of sick days, medication intake, fluctuations in blood sugar, implications of extra stress.
  • Management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar).
  • Prevention of long term problems through risk reduction strategies, including smoking cessation, heart-healthy eating, and awareness of diabetic neuropathy.
  • Education about proper foot care.
  • Travel tips.
  • Managing your emotional health through use of support groups and other resources.
  • Establishing a “self-care” chart that tracks the patient's self-care skills, relating nutritional intake, exercise, exposure to stress, medication intake, and blood sugar readings.

Outcomes

Clinical performance outcomes are monitored regularly. These functions include:

  • Blood glucose values
  • Hemoglobin A-1-C as ordered by the physician
  • Dietary compliance
  • Medication compliance
  • Demonstration of self care skills
  • Compliance with exercise regimes
  • Compliance with risk reduction strategies
  • Limiting of secondary complications
  • Emotional well-being/quality of life