# Presentation: 335010

## Diabetes in Pregnancy Program

- Processes of tracking case files using hard copy as well as RPMS and CMS computer systems.

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Quick ID of New Cases:

- Capture newly identified patients WITH sugar issues AND who are pregnant.
- 	> **Daily RPMS Bulletins                                                         **
-             ICD-9 codes 648.03, 683.83 and 648.93 **	**
**	****> Every Friday** Lab supervisor runs report all GTTs
- identifies 1 hr GTT abnormals to assist in making sure follow up  hr plans are in process by the clinic.
- 2.   3 hr GTT values used to ID the newly diagnosed patients for the DM & Preg Program.
- 3.   Post partum 2 hr GTT values to follow-up on moms and pass on abnormal non-postpartum or male patient values to appropriate case managers.

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Tracking a new DM in Pregnancy  

**Add person to excel list**
**maintain 3 different excel lists**
- CHO Intolerant (1 abn value on 3 hr GTT),
- GDM, and
- Pre-Gestational Diabetes.
**Headings: **name, chart#, PCP, EDC, 50 gm, FBS, 1 hr, 2 hr, 3hr, A1c,MNT Visit, Meter/Log Visit, PO Meds, Insulin, Del Date, Type, Sex, chart#, Weight, LGA/AGA/SGA, PP Appt, 2 hr GTT value, Notes, and Complications.
**Working hard copy** is a running list kept in a binder take on rounds clinics visits and on the inpt units.  update the computer version periodically.

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Registry in the RPMS Case Management System

- CHO Register
- GDM Register.
- Pregestational (DM2) patients are already on the DM2 register.
- Query these registers thru QMAN
- There are a lot of holes in what RPMS tracks with regard to prenatal patients - or at least I have not figured out yet how to glean some info so......

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Case Management Program Goals & Processes

**Reduction – **perinatal morbidity and mortality statistics
**Increased- **Diabetes Prevention Education for each family
**Increased – **visits with CM or RD to educate for future
**One page** hard copy reference for entire case progress
**Track **virtually everything of interest including infant outcomes.
**Update at each visit** and if the patient is **DNKA** - then chart review and begin contact process.
**Case notes** allow reminders of letters sent, what has been done and when.
**Closing the case** - gtt post partum done and normal or if DM2 - pt has a PCP assigned and is enrolled in DM clinic and pull the chart one final time to update my flow form for
**End of year** stats

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
Process goal as above
How about an impact of other morbidity measures 
You haven’t discussed hospitalization, adverse fetal events, stillbirth, misscarriage and infant resus or apgars. 

## DM and Pregnancy Program Flow Sheet

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## RPMS tracking

- Daily clinic tracking with RPMS
- print list appts w providers OB clinic using chart numbers to ID who the “sweet” moms are for that day
- pull flow chart and scan their health summary in RPMS.
- Problem:  written note on provider's list of appts as a reminder that something is missing, needs ordered, etc.  and I encourage them to send the pt to my department for ed/supplies/meter download/MNT, etc.  We are working on improving that.
- The only hole is Family Medicine where it would be impossible time wise to go through all of their appts but......it is not needed really because they always send their patients over for the DM & Preg Program visits so I just don't worry about tracking them to closely.  That clinic seems more used to chronic issue following,

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
I track who is being seen in the clinics every day.  I use RPMS for this.  I print a list of all appts with providers in the OB clinic and then use the chart numbers to ID who the sweet moms are for that day.  I pull their flow chart and scan their health summary in RPMS.  If there is a hole in the standard of care for that patient I note it on the provider's list of appts as a reminder that something is missing, needs ordered, etc.  and I encourage them to send the pt to my department for ed/supplies/meter download/MNT, etc.  We are working on improving that. The only hole is Family Medicine where it would be impossible time wise to go through all of their appts but......it is not needed really because they always send their patients over for the DM & Preg Program visits so I just don't worry about tracking them to closely.  That clinic seems more used to chronic issue following, etc.

## Case Load 2004

_**Cases**__ _- 118
- GDM - 58%
- Pregestational DM- 42%

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Time from Screen to Diagnosis

- Average EGA of 1 HR GTT –
- 	26 weeks  FMC -                28 wks - OBC
- Average days between ABN 1 HR and 3 HR
- 	12 days     FM Clinic          OBC  24.5 days
- 				  ( # cases in OB – 505, FM – 127)
- Average days between Dx and Meter/Education/MNT - 25 days
-  (difference between FM -  8 days and OB - 42 days )
- Days from ABN to Intervention Total
- Average 49.5 days and  33 weeks EGA House wide

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
I think I got some numbers mixed up here

So women are basically getting their screen in the 2nd to third trimester. 
Have you sorted out the lag between screen and 3 hour – maybe everyone should get the three hour up front? Lag in FMC is 12 days but lag in OB clinic is 45 days.  Main difference is a process one- MDs in FM take care of their own FU on labs – OB clinic providers do not have their own patients per se so FU is left to the midwife in clinic that day – OBs will not do labs for some reason.

We want to follow IHS guidelines and do the 1 hr at the first prenatal visit and then again at 28 weeks but have come up against opposition that we are working on currently.
I understand you are trying to compare to practice models – i.e. interventions

## Management

- Prenatal Visits - 589 - Average 10.7 per pt
- MNT Visits - 88 - Average 0.7 visits per pt ( Medical Nutrition Therapy)
- Case Manager/Education visits - 90 - 0.8 visits per pt
- Percent of GDM's without referral for a meter/no testing
- 11%  (8 pts) (all OB patients)
- Total # of Log Review visits with CM/RD
- 27% (26 pts) of post Dx visits
- Total # of Glucosuria results prior to GTT with no Accucheck
- 16% (96 pts) of visits
- Total # of GDM/DM pts with ketonuria and no MNT referral
- 22% (132 pts) of visits

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
Management goals here are to highlight how many visit lab issues should have sparked further follow-up.
Ketones – needs more kcals – MNT visit warranted
Glucosuria – probably needs an accucheck and plan for GTT if warranted
Really trying to get buy in from the OB clinic that visits with the CM and RD are not because they are doing something in error or even not doing something at all but to provide added services and education to clients.  Difficult area here right now.

## Maternal parameters

- Average weight gain - 18 lbs
- Percent of total cases on PO Meds - 24%
- Percent of total on Insulin - 25%
- Percentage of total cases on lifestyle changes =89% OBC, 100% FMC
- Average EGA at first scheduled NST - 34.8 weeks
- Percent of total cases without scheduled NSTs  31%  (23 pts: 22 from OB clinic, 1 from FMC)

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
Say something about life style changes (pedometer given along with MNT healthy eating education)– Alaska actually uses a treadmill in the clinic to get women walking. 

Class A 1      Class A 2
Did you have any B, C’s    
We are just now seeing B’s and C’s but in the 2005 list of cases
EGA at time of first NST – I take it that this is a QA issue and you have a range and a desired scheduled 
NST’s are recommended twice weekly at 28-32 weeks if HTN, renal disease or suspected IUGR, 32 weeks if on insulin and by 40 weeks if not on insulin.  

## Infant data

_**Birth Data:**_
- DM/GDM births at NNMC- 73
- Average EGA at birth - 38.7 weeks
_**Delivery Type:**_
- NSVD -72% (53 pts)
- C/S -28% (20 pts)

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
Do you have denominators? For total number of infants delivered- Yes but log form on L&D – no RPMS data base
How about those being transferred out?  Not currently tracking but good idea.  Might help to get total CHS dollars spent
Fetal maternal medicine specialists and eval for those with macrosomia. Not consistently at present but goal of program is to have a level 2 US on all DM in pregnancy fetuses – will be contract health issue since no specialists on board here.
Is the reason for section – dystocia/ failure to progress, distress, prior section? Adding this eval for 2005

## Infant data

_**Birth Weight**__:_
- AGA		45%  (33 pts)
- SGA** **		1.4%  (1 pt)
- LGA 		53%  (39 pts); 26% Macrosomic
- (+116 LGA/Macrosomic babies of mothers with no DM/GDM DX)

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Slide 14

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

## Postpartum data

**PP 2 HR GTT**
- 17/68  (25%) done overall
- 7/56 (13%) of patients from OB clinic with GTT done
- 10/12 (83%) of patients from FM clinic with GTT done
-         ******23% of completed tests have been abnormal
- CHO-intolerant not included in the above analysis

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico

**Notes:**
Completed in the first year = “done overall” ever
23% abnormal in the first year and they were GDM?   Wow! I Know

Your comments: 
“This initial report helped us to identify where we were with processes and areas needed to focus on/improve when I took this position in January of 2005.  The position was vacant for a couple years. “

## DM in Pregnancy Program – Next Step

**Focus – Diabetes Prevention**
- Utilizing NLB – Native Lifestyle Balance Curriculum – from the DPP
- Mom and Baby Friendly Weight loss Program for postpartum period
- Weekly classes – support group sessions

- Shelley Thorkelson CNM MSN, GDM Case Manager, Northern Navajo Medical Center (NNMC), Shiprock, New Mexico