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Amda Diabetes Guidelines

Pages From Diabetes Management

Pages From Diabetes Management

CPG CLINICAL PRACTICE GUIDELINE SERIESDIABETES MANAGEMENTin the Post-Acute and Long-Term Care Setting AMDA The Society for Post-Acute and Long-Term Care Medicine (AMDA) pro- vided the funding for the development of this guideline. The annual dues of the member physicians and other practitioners fund AMDAs work. A portion of the costs associated with the revision of this guideline were supported by a restricted grant from the Retirement Research Foundation. AMDA does not permit direct company support of the development of clinical practice guidelines or guideline revisions. Individuals in the work group that developed this guideline are not paid by AMDA, however, these individuals are volunteers. No members of the work group are employees, consultants, or speakers for a company with a commercial product within the subject matter of this guideline. AMDA facilitates and coordinates the guideline development and revision process. AMDA, its members, and peer organizations review and provide feedback, but do not have editorial control over the work group. All recommendations are based on the work groups independent evaluation of the evidence.For more information about the AMDA guidelines or to order copies of these clinical practiceguidelines, call 800/876-2632 or 410/740-9743 or visit our web site at www.amda.com.For guideline updates visit www.CPGNews.org.To cite this guideline use: American Medical Directors Association. Diabetes Management in thePost-Acute and Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2015 Original Panel Members: Lin Nyce, RD Ann OMalley, GNPNaushira Pandya, MD, FACP, CMD, Chair Carolyn D. Philpot, MSN, CS, GNP Roger A. Shewmake, Ph.D., L.N.Paul Block, LCSW-C Deborah Vincent, RN, DONKristen Graves, CNT, TMAE. Coy Irvin, MDBar Continue reading >>

Diabetes Management - Healthcap Usa

Diabetes Management - Healthcap Usa

Dr. Naushira Pandya, CMD and Dr. Meenakshi Patel were recently quoted in an article published by the American Medical Directors Association: In 2013 and beyond, diabetes management in the nursing home involves individualizing care and eliminating sliding scale insulin dosing. What does this mean to us, the caregivers of frail, elderly residents with diabetes diagnoses? It means a lot in how we manage the care of these individuals while maintaining blood glucose and HgbA1c levels. The article published in the June, 2013 issue of Caring for the Ages discusses why the use of sliding scale insulin in the management of diabetes in the elderly is no longer the standard. The goal of diabetes management is to prevent episodes of hypoglycemia. Studies have shown that the persistent use of sliding scale insulin regimens which can lead to both hypoglycemia and hyperglycemia has recently been singled out by several professional medical groups as a practice that should be replaced with more physiological approaches. Additionally, sliding scale insulin was added to the Beers Criteria in February 2012! Several new guidelines address diabetes management in the elderly. Though they differ somewhat on specifics, all generally call for personalization of treatment goals, less restrictive diets and looser numeric targets for blood glucose and blood pressure than those used to guide therapy in younger diabetes patients. In addition to the new guidelines, the AMDA also identified several potential F Tag citations related to diabetes outcomes including: F 309 Quality of Care residents with poorly controlled diabetes can experience symptoms of hypoglycemia that may result in neurological sequelae, hyperglycemia that can lead to malaise, worsening neuropathic pain, poor wound healing, incontin Continue reading >>

Amda / Paltc Diabetes Guidelines Pocket Guide & App

Amda / Paltc Diabetes Guidelines Pocket Guide & App

9. In general, patients with diabetes should be offered a regular diet 10. In general, metformin is preferred as an initial oral medication for the treatment of diabetes in the absence of absolute or relative contraindications 11. If treatment with insulin is required, basal insulin is the preferred initial choice if its use can achieve glycemic targets 12. The use of sliding-scale insulin alone to control blood glucose levels should be avoided 13. It is reasonable to aim for A1C targets between 7.5% and 8.5% for most patients, although higher targets may be appropriate for certain individuals 14. A blood-pressure goal of less than 150/90 is recommended for most older patients with diabetes 15. Statin therapy is recommended for all older patients with diabetes who are able to tolerate it and who lack contraindications 16. Blood glucose patterns should be reviewed regularly to allow logical adjustment of the pharmacological regimen 17. Patients being treated for diabetes should be monitored for the occurrence of hypoglycemia and the treatment regimen adjusted as necessary 18. The facility should monitor its management of patients with diabetes by measuring and tracking selected relevant process and outcome indicators Continue reading >>

Amda – The Society For Post-acute And Long-term Care Medicine

Amda – The Society For Post-acute And Long-term Care Medicine

Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home. SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regiments, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. Continue reading >>

North Carolina Alliance For Healthy Communities

North Carolina Alliance For Healthy Communities

Cancer: Breast Cancer :: Cancer: Cervical Cancer :: Cancer: Colon Cancer :: Cancer: Lung Cancer :: Cancer: Ovarian Cancer :: Cancer: Prostate Cancer :: Cancer: Skin Cancer :: Cancer: Uterine/Endometrial Cancer :: Chronic Kidney Disease :: Chronic Obstructive Pulmonary Disease :: Dementia / Alzheimers :: Depression :: Diabetes :: Heart and Vascular Disease: General Information :: Heart and Vascular Disease: Hypertension :: Heart and Vascular Disease: Cholesterol / Stroke :: Hepatitis C :: Migraines :: Obesity & Weight :: Osteoporosis :: Sinusitis What is the Provider: Wellness Promotion, Disease Awareness & Guidelines Resource Center? It is difficult and challenging for today's healthcare provider to keep abreast of the variety of quality initiatives, associations, disease state activities, insurers recommendations, wellness and preventive health services as well as disease focused national guidelines. This site is designed for the NC healthcare provider. In it you will find local and national organizations' resources focused on improving healthcare quality, reducing medical errors or facilitating the practice of national or evidence based treatment guidelines. Tips for creating an effective dialogue with patients can also be found specified by the "Ask Me Three" approach. Helpful national preventive and/or immunization guidelines along with coverage options for patients by NC insurers are highlighted. Resources to assist a patient in a smoking cessation program can also be found. Specifically designed for patients, a variety of on line healthcare risk assessment surveys are included to help promote disease awareness and/or severity focused on preventive health, a general HRA, alcohol use, BMI, asthma, CV disease, stroke, diabetes, 12 types of cancer, osteoporosis, deme Continue reading >>

Developing A Clinical Diabetes Guideline In Diabetes Research Network In Iran

Developing A Clinical Diabetes Guideline In Diabetes Research Network In Iran

Development of evidence-based clinical guidelines to raising standards of medical care in diabetes is a core element of coping with the global diabetes epidemic. The purpose of this study was to develop a systematic clinical diabetes guideline from the latest scientific evidences and also to localize its recommendations according to regional and cultural needs of our society. Searches were conducted using NICE, SIGN, WDPCP, IDF, JDC, ADA, AACE, ICSI, CDA, AMDA, IDC, NyDoH guidelines which were examined and criticized and scored using Agree method. Guidelines which got higher score in some important areas of Agree scale including: rigor of development, clarity and comprehensiveness of the recommendations and applicability, especially in the climatic conditions of our country were selected. The existing recommendations were extracted by committee members and supporting evidences of each recommendation were determined based on the sources listed in the clinical guideline. Recommendations grading were classified from grade A to D based on the quality of their supporting evidences (BEL1-5). This guideline covered all areas related to diabetes including screening and diagnosis, lifestyle modification and patient education, management, complications and hypoglycemia. Regarding capacities of this guideline and lack of comprehensive and updated guidelines in our country and region, it is suggested that designing a pilot study to implement this Learner-centered guideline and finding its weaknesses can lead to patient care improvement and also propel us towards our goal to design a comprehensive guideline in compliance with regional and national needs in Middle East. The snippet could not be located in the article text. This may be because the snippet appears in a figure legend, Continue reading >>

Delirium And Acute Problematic Behavior In Ltc Patients: Whats The Best Approach?

Delirium And Acute Problematic Behavior In Ltc Patients: Whats The Best Approach?

Delirium and acute problematic behavior in LTC patients: Whats the best approach? Clinton Memorial Hospital/University of Cincinnati, Family Medicine Residency, Wilmington, Ohio Clinton Memorial Hospital/University of Cincinnati, Family Medicine Residency, Wilmington, Ohio Expanded recommendations draw on recent research, and on insights from hands-on practitioners in long-term care. 1. Ebell M, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Fam Pract. 2004;53:111-120. 2. Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113:941-948. What are the best methods to assess delirium and acute problematic behavior in the long-term care setting? What is the most appropriate treatment for these patients? Why is monitoring of interventions critical to patient outcomes? The answers to these questions are summarized at right and in the 2008 edition of Delirium and Acute Problematic Behavior in the Long-Term Care Setting, published by the American Medical Directors Association (AMDA). This comprehensive guideline, developed to improve quality of care, features a 15-step systematic approach to recognizing, assessing, treating, and monitoring long-term care patients with delirium and acute problematic behavior. It includes a simple algorithm to guide the decision-making process. Delirium and acute problematic behavior are common in the long-term care setting, but management guidelines have been limited. To assist physicians, advanced practice nurses, nurses, and allied health professionals in long-term care facilities, the AMDA developed the initial version of this guideline in 1998. A multidisciplinary workgroup used a Continue reading >>

Improving Outcomes Through A Coordinated Diabetes Disease Management Model

Improving Outcomes Through A Coordinated Diabetes Disease Management Model

Improving Outcomes Through a Coordinated Diabetes Disease Management Model Cristi L. Day, DNP, RN, FNP-C, ADM-BC 1 Susan Kimble, DNP, RN, ANP-BC 2 An-Lin Cheng, PhD 2 Annals of Long-Term Care: Clinical Care and Aging. 2014;22(9):38-44. 1College of Nursing & Health Sciences, Texas A&M University, Corpus Christi, TX 2School of Nursing & Health Studies, University of Missouri, Kansas City, MO Abstract: Nursing home residents are often medically complex, and there is a high prevalence of diabetes mellitus in the presence of one or more acute conditions. Outcomes for this patient population have been shown to improve with an interdisciplinary team approach to disease management. The authors conducted a quality improvement initiative that sought to measure and improve diabetes outcomes in a long-term care population at a corporately owned 112-bed nursing home located in South Texas. The team implemented evidence-based care using a specialized nurse practitioner within the coordinated diabetes disease management (CDDM) model. The AMDA The Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association) evidence-based diabetes guidelines were employed for clinical decision-making. The authors found that their project led to significant improvements in patient outcomes, including reductions in hypoglycemia incidence and sliding scale insulin orders, while increasing resident-centered care and improving chronic kidney disease screenings. Nursing home residents with diabetes represent a heterogeneous population; thus, implementation of patient-centered disease management strategies is essential to improving outcomes and quality of life in this population. Use of a specialized healthcare practitioner to coordinate interdisciplinary diabetes Continue reading >>

Management Of Diabetes In Long-term Care And Skilled Nursing Facilities: A Position Statement Of The American Diabetes Association

Management Of Diabetes In Long-term Care And Skilled Nursing Facilities: A Position Statement Of The American Diabetes Association

Published online 2016 Jan 11. doi: 10.2337/dc15-2512 Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association 1Beth Israel Deaconess Medical Center and Joslin Diabetes Center, Harvard Medical School, Boston, MA 2Geriatric Research Education and Clinical Centers, Miami Veterans Affairs Healthcare System and University of Miami, Miami, FL 3Section of General Internal Medicine, The University of Chicago, Chicago, IL 4Johns Hopkins University School of Medicine, Baltimore, MD 5American Diabetes Association, Alexandria, VA 6Department of Geriatrics, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL 7Kadlec Regional Medical Center, Richland, WA 8University of Rhode Island College of Pharmacy, Providence, RI Copyright 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. This article has been cited by other articles in PMC. Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tail Continue reading >>

Diabetes In Long-term-care And Skilled Nursing Facilities: The Ada Position Statement

Diabetes In Long-term-care And Skilled Nursing Facilities: The Ada Position Statement

US Pharm. 2016;41(10)(Diabetes suppl):7-11. ABSTRACT: As the number of elderly people in the United States continues to rise, an increasing proportion of older adults will develop diabetes and will need long-term or skilled care. In early 2016, the American Diabetes Association issued a position statement on the management of diabetes in long-term-care and skilled nursing facilities. This statement provides recommendations for the general approach to care; goals and strategies for glycemic control; diabetes management during transitions of care and end of life; and suggestions for integration of diabetes management into long-term-care facilities. Pharmacists can play an active role in each of these areas in order to help optimize glycemic control in their patients. The prevalence of diabetes in the long-term-care (LTC) setting is estimated to range from 25% to 34%,1 which is equal to or higher than trends seen in the general population. The latest National Diabetes Statistics Report (2014) estimates that, in the United States, 25.9% of persons aged ≥65 years have diabetes, compared with 16.2% of those aged 45 to 64 years and 4.1% of those aged 20 to 44 years.2 Among persons aged 65 to 74 years and those aged ≥75 years, there was an increase of 113% and 140%, respectively, in the rate of diagnosed cases of diabetes from 1993 to 2014.3 Diabetes is the seventh leading cause of death in the U.S.2 As baby boomers continue to age, the proportion of older adults with diabetes who will need nursing homes (NHs) or skilled care is expected to rise. Pharmacists who serve residents in the LTC environment must be prepared to meet this challenge. Type 2 diabetes (T2D) accounts for 90% to 95% of diabetes in the U.S. Age-related changes in older adults that predispose them to the T Continue reading >>

Icp - Icp: Articles

Icp - Icp: Articles

As seenin theConsultant Connection July 2016 Issue Tracey Pierce RPh, CGP, FASCP, Consultant Pharmacist In a recent publication of Diabetes Care (Diabetes Care 2016;39:308-311) the American Diabetes Association released a position statement for strategies and goals of diabetes management in LTC. Three specific patient populations seen in long term care were identified: 1)Transitional care/rehab; 2) general LTC; and 3) hospice/palliative care. Each of the 3 areas have unique problems, goals, and treatment strategies. A truly patient specific approach is necessary due to the complexities of the patients, complicating comorbidities, and transitions in care. A change in approach to diabetes management is underway in LTC. The tight glycemic control that is the goal of treatment in younger patients and hospitalized patients is not appropriate for the frail elderly due to the risk of hypoglycemia and the complications that occur. The risk for hypoglycemia is greater in the elderly due to decreased renal function, variable appetites, cognitive impairment, altered GI motility, and altered GI absorption. This risk is compounded by recent hospitalization, advanced age, medication changes, and polypharmacy. Some general guidelines for diabetes care in the elderly residing in LTC include: Consider discontinuing medications not providing comfort Tight glycemic control in younger persons will improve and increase longevity along with decreasing complications of diabetes. However, in the frail elderly, this risk of hypoglycemia outweighs any benefits of tight control due the frequency of hypoglycemia and to the potential increased costs of care due to complications of hypoglycemia and its management. Signs of hypoglycemia in the elderly may not be typical (palpitations, sweating, trem Continue reading >>

Code Ulcers Appropriately

Code Ulcers Appropriately

By Valerie Fernandez, MBA, CPC, CPC-H, AHIMA ICD-10 Trainer Even though the implementation of ICD-10 has been delayed for a year, it is important to consider how to appropriately code specific medical conditions. Ulcers represent one general diagnosis category that require specificity under ICD-10. We will start with the basics. Documentation requirements for ulcers include the following: indicating the type of ulcer and the location, laterality, and stage. The chart in Figure 1, which comes from the American Medical Directors Association Clinical Practice Guidelines (AMDA CPG), provides a summary of the distinguishing features of various types of ulcers, as well as the location where they often appear. A pressure ulcer is an injury to the skin occurring when a patient sits too long or remains in the same position. When this happens, the cells and tissue in that area die, resulting in an open sore. In severe cases, the muscle, tendon, or bone may begin to show. Pressure ulcers occur on pressure points, such as the tailbone, buttocks, elbows, heels, and hips. There are four stages of pressure ulcers. The table in Figure 2 provides details on each stage. The physician must document the presence of a pressure ulcer. Any associated gangrene is coded first, as I96. In ICD-10, there are 150 codes for pressure ulcers. Listed below are several examples of ICD-10 codes for ulcers: Pressure ulcer of right elbow: unstageable L89.010 Pressure ulcer of right elbow: stage I L89.011 Pressure ulcer of right elbow: stage 2 L89.012 Pressure ulcer of right elbow: stage 3 L89.013 Pressure ulcer of right elbow: stage 4 L89.014 Diagramed on page 38 (Figure 3) are the ICD-10 diagnosis code characteristics for a pressure ulcer of the right elbow, stage 1. A venous stasis ulcer is a breakdown Continue reading >>

Managing Diabetes In The Long-term Care Setting: Strategies And Tools

Managing Diabetes In The Long-term Care Setting: Strategies And Tools

Back when we started practicing, every patient was supposed to have a glycated hemoglobin level (HbA1c) of less than 7%. I think we have gotten much more realistic about that in terms of trying to match HbA1c target goals to the needs of the patient. And for patients in LTC facilities, which is mainly the elderly population, the HbA1c target goal is not just less than 7% without hypoglycemia. We have to also look at the patient's comorbidities and life expectancy. Does the patient have cardiovascular disease? Do they have hypoglycemia unawareness? What resources do they have? Do they live alone? Are they taking medications that cause hypoglycemia? All of these factors are important when we establish a target HbA1c ; if you have an elderly individual who is in their 80s, their individualized HbA1c target may be 8 or 8.5%. [1] Ms Novak: We have to be even more conservative when patients are in an LTC facility because those patients are not only more ill, they are also compromised as far as what they can do for themselves and relying on others to actually do for them. The limitation of the HbA1c, especially in patients with diabetes who have an elevated HbA1c, is that they have the same risk of hypoglycemia as patients with an HbA1c closer to 7% or 6.5%. A study by Lipska and colleagues showed that the HbA1c is quite deceiving and that the risk of hypoglycemia is quite high in patients with an elevated HbA1c, [2] so we cannot use that as a tool to determine whether or not we need to change a patient's medication or adjust the dose. The HbA1c should only be used as a ballpark number; glucose monitoring is what is important when it comes to actually changing medications, managing a patient, and generally keeping a patient safer. Ms Kruger: I agree with that, because you wan Continue reading >>

Best Practices In Diabetes Management

Best Practices In Diabetes Management

Through my work with the Endocrinology Department in Tirana, Albania, I have developed an interest and expertise in the care of persons with Type 2 Diabetes. However, this is a rapidly changing field, so I attended the online Webinar from AMDA on 3/7/18 with great interest. Dr. Naushira Pandya is a former President of AMDA and a recognized expert on this subject in the PA/LTC setting. She was a part of the latest ADA update on diabetes care in our setting, January 2016. Ill share a few pearls below, but encourage you or your facility to listen to the power point presentation. Its available at: . Its free for AMDA members, but $99 for non-members. Here are some pearls: 1. Some of the variability we see in finger-stick glucose measurements is likely due to errors administering insulin by syringe or pen, wrong size needles, wrong angle of injection, & failure to rotate site or injecting into lipodystrophy or atrophy sites. She has 3 slides with detailed recommendations for reducing these errors. For facility training the FIT UK Forum for Injection Technique UK, is quite helpful. Its available at 2. Sliding Scale Insulin (SSI) without basal insulin coverage is high-risk for poor glycemic control with increased risk for serious hypoglycemic episodes. Facilities are starting to be cited for this substandard practice. However, basal insulin + SSI without meal rapid acting insulin is permissible since there is no evidence yet for increased risk of hypoglycemia. 3. Once a person with Type 2 IDDM is stable with finger-stick Glucose in desired target range, the frequency of finger-stick Glucose measurements can be reduced as long as the patient remains medically stable. This can be safely done by block testing. For instance, FS Glucose test a.c. tid + h.s. could be reduced to a.c Continue reading >>

Implementing The Amda Diabetes Toolkit And Cpg And Assimilating New Information Into Current Management - Long Term Care Medicine-2010 - Amda - The Society For Post-acute And Long-term Care Medicine

Implementing The Amda Diabetes Toolkit And Cpg And Assimilating New Information Into Current Management - Long Term Care Medicine-2010 - Amda - The Society For Post-acute And Long-term Care Medicine

The American Medical Directors Association (AMDA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Medical Directors Association designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. This session has been approved for a total of 1.5 Management credit hours toward certification as a Certified Medical Director in Long Term Care (CMD). This session discusses practical ways to transition diabetes care from the acute care setting to the long term care setting using the principles described in the AMDA CPG, while understanding the new studies and how they change treatment strategies. Disucss the practical approach to transitioning diabetes care from acute care setting to long term care. Implement the AMDA guideline and toolkit. Apply the data learned from the ACCORD ADVANCE and VADT trials to current management guidelines. Meenakshi Patel, MD, CMD; Naushira Pandya, MD, CMD Meenakshi Patel, MD, CMD - Sanofi Aventis: Speaker; Novo-Nordisk: Advisory Board Naushira Pandya, MD, CMD - Sanofi-Aventis: Speaker Honorarium; Novo Nordisk: Speaker's Bureau (No Honorarium) AMDA diabetes guideline and toolkit Type 2 Diabetes Therapy and Cardiovascular Events: Comparing VADT With Other Trials Duckworth W, Abraira C, Moritz T, et al; for VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360(12):129-139. . ACCORD Trial: Intensive Blood Glucose Control in Patients With Type 2 Diabetes The ACCORD Study Group. N Engl J Med. 2008;358(24):2545-2559. ADVANCE: The ADVANCE Collaborative Group. N Continue reading >>

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