Diabetes Management Clinic. Physician Referral and Protocol Agreement I, as the patient, understand that my diabetes is to be monitored and cared for …
Diabetes Management Clinic
Physician Referral and Protocol Agreement
Patients name_______________________ Identification
____________________
Physicians name_____________________
I authorize pharmaceutical care to be conducted by
____________________________ in accordance with the following protocol for
diabetes management All of the following services will be performed
unless specifically limited by the referring physician :
Please place a check by those you do NOT wish to be performed by the
pharmacist
1 Provision of basic drug/disease state education and counseling,
providing written educational materials as needed
2 Review of lifestyle modifications appropriate for diabetes and
assessment of current compliance with these practices
3 Initiation and/or modification of drug therapy for diabetes vs Making
recommendations for changes in drug therapy and laboratory monitoring
Selection of blood glucose meter, instruction in proper use and
monitoring of results
Instruction on proper insulin storage, dosage preparation, injection
techniques, and syringe disposal for patients on insulin
Monitoring of drug therapy for compliance, drug
interactions, and
effective outcomes
Laboratory results will be provided by the clinic as requested by the
pharmacist
Last HbA1C: ________________________________ Date:
_________________
Special Instructions:_____________________________________________________
_____________________________________________________________________
This protocol is valid for one year from the date shown below
________________________ ________________________ _______________
Pharmacists signature Physicians signature Date
I, as the patient, understand that my diabetes is to be monitored and cared
for by the pharmacist as described in the protocol agreement above
_____________________________________ __________
Patients signature Date
Protocol for Diabetes Management Clinic
The following is a description of the services that are listed in the
Protocol Agreement:
A Provision of drug/disease state education
Counsel patient on purpose and proper administration of all current
medications and any new medications added to current regimens
Provide basic Diabetes Education encompassing the following areas:
Pathophysiology of diabetes mellitus
Goals for therapy
Symptoms of hyperglycemia and hypoglycemia
Complications of diabetes
Proper foot care
Sick day management
B Instruct patient on healthy Lifestyle Modifications
Compliance with a low-fat, low-cholesterol diet
Weight loss in overweight patients
Appropriate physical activity
Smoking cessation
Limiting alcohol consumption
C Collaborative therapy management
Two alternatives for section C
1 Initiation/modification of drug therapy
Insert your plan for modifications of drug therapy here
Alternatively
2 Provide recommendations to physician regarding drug therapy and
appropriate laboratory monitoring
Describe method by which the recommendations will be transmitted to the
physician ie by faxed progress note, phone call, letter, etc
D Blood glucose meters
Select/obtain appropriate glucose monitor for patient
Instruct patient on proper use, care and maintenance of the meter
Observe patient perform a test and demonstrate competence in care and
maintenance of the meter
Review records of self monitored glucose at each visit
E Instruction on
proper use of insulin
Storage
Mixing technique
Injection technique
Syringe disposal
Use and care of insulin pens
Use and care of insulin pumps
F Monitoring of drug therapy
Compliance with medication regimen
Drug interactions
Occurrence of hypoglycemia or hyperglycemia
Effective outcomes to be monitored include
HbA1c
Percentage of self monitored blood glucose readings that are within
goal range
OUTCOME MEASURES FOR DIABETES MANAGEMENT
1 Serum glucose is within the acceptable range
2 Improved average serum glucose reduction
3 Favorable changes in HbA1C
4 Weight loss
5 Decreased insulin dose with same control
6 Decreased DM-related hospital admissions
7 Decreased DM-related ER visits
8 Decreased DM-related unscheduled visits to physicians office
9 Favorable foot examination outcomes
10 Patients being immunized on schedule eg, influenza and pneumococcal
as appropriate for age
11 Fewer missed work/school days
12 Other potential outcome measures
a Fructosamine measures
b Lipid panel performed at least annually
c Urinary albumin performed at least
annually
d Blood pressure treated with ACE inhibitors
e Patient has received foot exam at least annually
f Ophthalmologic exam performed yearly
g Percentage of pharmacist recommendations that are followed
Source:olemiss.edu
