information to KHPA regarding the needs of Medicaid beneficiaries with diabetes. current case load have a diagnosis of diabetes and one or more other chronic …
The following survey should be completed by the Home Health Agency
Administrator or Director of Nursing The survey will provide valuable
information to KHPA regarding the needs of Medicaid beneficiaries with
diabetes The information is instrumental to the Diabetic Management
Project and future changes to the home health program
Questions one through eight require a numerical response regarding case
load
1 What is your agencys current case load? _____
2 How many clients on your current case load are Medicaid beneficiaries?
_______
3 How many clients on your current case load are dually eligible
eligible for both Medicare and Medicaid? ______
4 How many Medicaid beneficiaries on your current case load have a
primary diagnosis of diabetes 25000 - 2509 or long-term use of
insulin V5867? ____
5 How many Medicaid beneficiaries on your current case load have a
diagnosis of diabetes and one or more other chronic diagnoses such as
coronary artery disease, congestive heart failure, or chronic
obstructive pulmonary disease? ________
6 What is the average length of home health episodes of care for
Medicaid
beneficiaries with diabetes?
a Days _______
b Weeks ______
c Months ______
d Other ________
7 Please note the number of Medicaid beneficiaries with a diagnosis of
diabetes that receive skilled nursing visits at the following
intervals:
a Daily______
b Twice daily_____
c Three times per day______
d Four times per day______
e Weekly_________
f Other________________________________
8 Please note the number of Medicaid beneficiaries with a diagnosis of
diabetes that also receive services through an HCBS Home and
Community Based Services waiver_______
Questions nine through twelve require a Y or N response
9 Does your agency have a structured diabetic management program?
______Y_____N
10 Does your agency provide training and education for management of
diabetes, utilizing best practice guidelines? ______Y ______N
11 If training is provided, does your agency teach and train family
members or other caregivers to provide diabetes care? _______Y
_______N
On question 12, please circle Y or N as applicable related
to topics
included your agencys diabetic management training program
12 Does your agencys diabetic management training address the following
topics related to diabetes?
|Signs of hypoglycemia Y N |
|Signs of hyperglycemia Y N |
|Use of glucometer Y N |
|Acceptable blood glucose ranges Y |
|N |
|Hemoglobin A1C Y N |
|Insulin administration Y N |
|Rotation of injection sites Y N |
|Blood pressure Y N |
|Blood cholesterol Y N |
|Eye examinations Y N |
|Foot care Y N |
|Skin care Y N |
|Weight management Y N |
|Nutrition Y N |
|When to seek medical assistance Y |
|N |
|Smoking cessation Y N
|
|Exercise Y N |
| r Proper oral care Y |
|N |
13 What criteria are used to determine that a beneficiary is not able to
self manage his/her diabetes and will require long term agency
management of their diabetes? Please check all applicable criteria
a Physical limitations poor vision, fine motor deficits _____
b Cognitive limitations _____
c Caregiver unwilling _____
d Caregiver unable _____
e No available caregiver _____
f Other, please explain
______________________________________________
14 On average, how much time is required per visit for effective
diabetic management education for a newly diagnosed beneficiary?
__________________________________________________________________
15 What are your recommendations or suggestions to ensure that Medicaid
beneficiaries with diabetes receive comprehensive quality care? Please
include you suggestions in the space below
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
__________________________
Thank you
