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ADA Standards of Care for Members with Diabetes STANDARD OF CARE HBA1-C TESTING LDL-C TESTING OR A LIPID PANEL WHAT IS THIS? WHY IS IT IMPORTANT? This test shows the average amount of glucose in the blood over the last 2-3 months and indicates if a person's diabetes is under control. Keeping low density lipid cholesterol (LDL-C) under control is recommended to decrease the incidence of heart attack and strokes. Comple- tion of this test is the most-often used indicator of quality care for persons with diabetes. BLOOD PRESSURE & CONTROL OF B / P SCREENING FOR KIDNEY DISEASE OR NEPHROPATHY DILATED RETINAL EYE EXAM TESTING FOR NEUROPATHY & FOOT EXAMINATIONS HEALTH MAINTENANCE OR WELLNESS EXAM IMMUNIZATIONS High blood pressure leads to strokes, kidney and heart damage. Several interventions can reduce the risk and slow the progression of renal disease for people who have diabetes. HOW OFTEN SHOULD THIS BE DONE? Test HbA1c every 6 months if the patient is in good control and at least twice a year. LDL-C testing should be done annually. While a fasting lipid profile is the preferred way to test a member, a non-fasting direct measurement of LDL-C can be performed to determine if treat- ment for hyperlipidemia is required. Blood pressure should be checked at every visit. ADA RECOMENDATIONS OR TREATMENT GOALS The recommended level is < 7.0% when appro- priate for the patient. The LDL cholesterol goal is <100 mg/dL. Control hypertension with ACE/ARB and/or other medication as appropriate. Treat to a blood pressure of <130/80 mmHg. Perform an annual test to assess urine albumin excre- tion in type 1 DM patients w/ a duration of ≥ 5 years of diabetes and in all type 2 DM patients upon diag- nosis. An annual urine screening for microalbuminuria is recommended, if appropriate. Measure serum creatinine at least annually in all adults w/ diabetes. A dilated eye exam can detect early disease, which allows early treatment which is important in an effort to prevent blindness. Persons with diabetes may lose sensation in their feet, and not notice a potential problem. Teaching self-foot inspection and care allows early treatment of problems. Preventive healthcare is the cornerstone of prevention of diabetes complications. Influenza, Pneumococcal and Hepatitis B vaccines prevent life threatening illnesses in persons with diabetes. NUTRITION EDUCATION Learning to monitor carbohydrates is a key strategy to help people with diabetes control their blood sugar levels. Nutrition education is an essential component of self-management and control of diabetes. A dilated retinal eye exam should be done on an annual basis. For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors for ulcers or amputations. Have the patient remove their socks and shoes at each visit, so a quick foot exam can be completed. Provide preventative health care at every visit as needed. Check to see if your member needs testing at each visit. Check vaccine status at every visit, and reach out to members to get an annual flu shot before the flu season. Administer Pneumococcal vaccines and a Hep B series as indicated. Inquire about your patient's past participation in nutrition & self-management classes. As self-management skills improve, complications can be prevented. Refresher courses for diabes education should be considered. Treatment with ACE inhibitors or ARB's should be used in the non-pregnant patient with micro- or macroalbuminuria. Referral to a nephrologist may be indicated when nephropathy is present. Refer members with diabetes to an optom- etrist or ophthalmologist every year or perform dilated retinal exams in your office. A foot exam should include inspection, assessment of foot pulses, and testing for loss of protective sensation w/a 10-g monofilament, a tuning fork, or by pinprick sensation. Testing of ankle reflexes should also be performed. Refer to podiatry as needed. An annual health maintenance exam is recom- mended, as well as continuing medical care for diabetes. Provide annual flu vaccine for diabetic members > 6 mo. old. One lifetime pneumococcal vaccine w/revaccination at 65 yr. if last vaccine was ≥ 5 yr. ago. Complete a Hep B series for all < 60 yr. or at provider's discretion if >60 yr. Upon diagnosis, a person with diabetes should receive individual nutrition therapy, preferably by a registered dietician. Ongoing education about nutrition and self management should be offered. Adolescents may benefit from annual nutrition education and self management classes. The complete ADA standards of care can be found at: http://care.diabetesjournals.org/content/35/Supplement_1/S11.full making managed care work for you • CMCS connections special insert • 2nd quarter 2012