lifestyle modifications appropriate for diabetes and assessment of current 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 G Provision of basic drug/disease state education and counseling, providing written educational materials as needed G Review of lifestyle modifications appropriate for diabetes and assessment of current compliance with these practices G 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
