Policy and Procedure Manual

 

The

Policies and Procedures

of

The Cherokee Diabetes Program

 

 

 

Table of Contents

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Accu-chek AdvantageR Instrument Quality Control and Maintenance

PURPOSE: To ensure validity of results; to ensure optimal functioning of
the Accu-chek AdvantageR instrument.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

REFERENCE: Addendum 10 - 14

POLICY:

Staff will maintain the instrument and perform quality control checks
according to the Accu-Chek Advantage User’s Manual.

PROCEDURE

Quality Control

  1. The quality control is to be performed daily.
  2. Insert the Check strip “Chek” side up into the meter. The meter turns on automatically.
  3. Verify that the code number matches the code number on the vial of test strips. The meter quickly goes through a series of internal check to verify that it is working properly.
  4. “OK” and a check mark will then appear on the display.
  5. Remove the Check Strip from the meter.
  6. The test strip symbol flashes. “L1” and a check mark appear on the display.
  7. Insert a test strip (yellow window facing up) into the test strip slot. The test strip symbol stops flashing and the flashing blood drop symbol appears.
  8. Hold the low control bottle horizontally with the tip pointed directly at the right edge of the strip and apply one small drop.
  9. A box rotates in the display until the measurement is complete.
  10. A control result will appear. If the result is within the acceptable range printed on the test strip vial, the test result and the “ok” and check mark alternate on the display. If the result is not within the acceptable range printed on the test strip vial, the test result and “error” and check mark alternate on the display.
  11. Remove the test strip from the meter and discard it.
  12. The test strip symbol “L2” and check mark appear on the display. The test strip symbol flashes.
    13. Follow the same procedure using the high control solution
  13. If the result is outside of the acceptable range:
  • Check the expiration date of the test strips and control solutions. If the strips or control solution is expired, dispose of them promptly.
  • Make sure the cap was placed tightly on the vial of test strips and control solution. The test strips and control solutions can be damaged when they are not capped and stored properly.
  • Check if the code in the meter matches the code on the test strip vial label.
  • Make sure that you followed the steps exactly.
  • Repeat the glucose control test with a new test strip.
  • Notify the program manager if the result is still not in acceptable range or call the manufacturer at 1-800-858-8072.

Maintenance Procedure.

  1. Keep the test strip holder and the test area clean.
  2. Do not drop the meter
  3. Avoid extreme temperatures for both the meter and the strips.
  4. Never let the meter get wet.
  5. Do not take the meter apart.
  6. Inspect the meter daily for lint, dirt, or particles on the meter.
  7. Clean the meter using 70% alcohol daily.


 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Unstable and/or Acutely Ill Patients

PURPOSE: To ensure that any patient who presents to or becomes acutely ill or unstable during a visit at the Cherokee Diabetes Program receives immediate priority and appropriate attention.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 01/04

DATE REVIEWED OR REVISED:

DISTRIBUTION: CDP Staff

PROCEDURE:

Any individual deemed medically unstable or acutely ill should be immediately sent to the emergency department at CIHA if they:

  1. complain of chest pain
  2. complain of shortness of breath (other than chronic)
  3. complain of any severe pain
  4. complain of pre-syncope/dizziness unrelated to hypoglycemia and unresolved after administration of glucose tablets.
  5. syncope/disorientation/change in mental status
  6. any symptomatic individual with the following vital signs:
    1. Systolic blood pressure < 90mmHg
    2. Heart Rate < 45 bpm.
    3. Respiratory Rate >30
    4. Oxygen saturation (Sp02) < 90%
  7. Evidence of shock including pallor, diaphoresis, unstable vital signs

The program manager and appropriate provider should be notified of this situation.

If a patient becomes unconscious/unresponsive, the CDP staff should:

  1. Ensure patient safety by laying them on a flat surface and protecting their head.
  2. Follow BCLS guidelines in assessing/maintaining airway, breathing, and circulation.
  3. Call 911 or 497-4131(Cherokee EMS)
  4. Obtain a CDP provider ASAP
  5. Provide the patient with oxygen
  6. Place patient on Automated External Defibrillator (AED) to monitor vitals.
  7. DO NOT move patient until EMS has arrived


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Advisory Committee

PURPOSE: To assist with planning the overall diabetes program, recommend policy,
and review program performance at least annually.

STAFF GOVERNED BY THIS POLICY: CDP Staff, Advisory committee

EFFECTIVE DATE: 07/99

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff, Advisory committee members

POLICY:

Advisory committee membership includes health professionals and others interested in the care and education of people with diabetes within the Eastern Band community. Permanent members of the committee include:

  • program manager
  • program physician
  • program mid-level practitioner
  • program nurse educators
  • program nutritionists
  • program diabetes support therapist/advocate
  • community members

Representatives from Tribal administration, Indian Health Services, and other health programs serve as ad hoc members. The program manager serves as the chair of the committee. Meetings are held as frequently as the committee feels necessary. The committee meets at least annually. Members are encouraged to attend all meetings but must attend at least one meeting annually.

The committee specific committee responsibilities are:

  1. Planning: review and recommend changes in program objectives, target audience, participant access mechanisms, instructional methods, program resources, procedures for participant follow-up program evaluation plans, and approve the annual program plan.
  2. Policy recommendation: approve new program policies or recommend policy revisions, recommend policy changes, provide follow-up on recommended and approved policies.
  3. Evaluate annual program performance: completion of objectives, comparison between actual and target audience, participant access to the program, program follow-up mechanisms, adequacy of program resources, curriculum and educational materials, marketing strategies and effectiveness, overall program effectiveness as evidenced by quality assessment/performance improvement measures.
  4. Recommending program revisions.

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Employee Call-outs/Sick leave

PURPOSE: To ensure communication for the purpose of program scheduling when an
employee must be out sick or late.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY:

When an employee must miss work due to illness or family illness, or must
arrive late for work, the program manager must be notified. Notification should also be made to receptionist or administrative assistant.

PROCEDURE:

  1. During working hours, the program manager should be notified.
  2. After working hours, program manager should be contacted at home or on cell phone, as well as the administrative assistant (in the event that the program manager is out) so that alternative arrangements for staff coverage can be arranged.
  3. Request for sick leave pay must be submitted on the appropriate form and attached to a time sheet reflecting the absence to the program manager.

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Capillary Blood Glucose Measurements using the Accu-chek AdvantageR
Instrument

PURPOSE: To ensure appropriate technique of capillary blood glucose monitoring
using the Accu-chek AdvantageR instrument.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

REFERENCE: Accu-Chek Advantage ®User’s Manual.
Addendum: 10 - 14

POLICY: Staff will utilize the instrument according to the Accu-Chek Advantage ®User’s Manual.

PROCEDURE:

  1. Have the patient hang their arm down to facilitate blood flow to the fingers.
  2. Remove a new test strip from the vial. Always use comfort curve test strips.
  3. Insert the test strip (yellow window facing up) into the test strip slot on the meter. Check that the code number displayed matches the code number on the vial of strips. When the blood drop symbol flashes, you are ready to perform a test.
  4. Prepare the lancet device.
  5. Prep the site using an alcohol sponge. Allow the site to dry.
  6. Grasp the finger near the area to be pricked and gently squeeze for three seconds.
  7. Keeping the hand down, prick side of the fingertip and squeeze gently until you get a drop of blood.
  8. With the strip in the meter, touch and hold the drop of blood to the edge of the strip. Bring the finger and the strip together. The blood will be drawn into the strip automatically – do not place the blood drop on top of the yellow window. Allow the window to completely fill with blood.
  9. When the blood is applied to the strip, a box rotates on the display until the measurement is completed.
  10. The blood glucose result is displayed and automatically recorded in the meter’s memory.
  11. Remove the test strip from the meter and discard it.
  12. If the meter displays the message “HI”, notify the medical provider immediately.
  13. If the meter displays the message “mg/dL” or “error”, perform a quality control check and re-perform the test again using a different instrument.

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Caseload for Mid-level Practitioners

PURPOSE : To delineate provider roles and case loads

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 05/02

DATE REVIEWED OR REVISED: 11/04

APPROVED BY: Lisa Wheeler, MS Ed, PA-C Ann Bullock, MD
Program Manager Medical Director

DISTRIBUTION: CDP Staff

POLICY: Mid-level practitioners in the Cherokee Diabetes Program will follow guidelines listed below in managing patients with diabetes.

The mid-level practitioner may provide primary care to the patients with the following:

  1. Minor acute illness
  2. Hypothyroidism
  3. Cancer history if not undergoing chemo or radiation
  4. Requiring HRT/OCP
  5. Anticoagulation if the patient is being followed by the anticoagulation team
  6. Chronic pain patients who are having narcotics filled through the pain clinic team
  7. Any other patient approved by the supervising physician or medical director of Health and Medical.

Diabetic patients with the following conditions shall be screened by the supervising physician or medical director to determine appropriateness of the patient being placed on a mid-level providers case load. While these patients may be managed by the mid-level provider, close consultation shall occur between physician and mid-level:

  1. Creatinine > normal
  2. Documented CVD
  3. Uncontrolled hypertension on 4 or more antihypertensive medications.
  4. Pregnancy (Can be diagnosed, but then transferred to prenatal clinic or whomever will provide prenatal/obstetrical care.)
  5. Diabetes-associated amputations
  6. Significant peripheral vascular disease
  7. Chronic foot ulcers
  8. Type 1 diabetes

Collaboration must exist between in the mid-level and the supervising physician with respect to managing these patients. The supervising physician should be updated on patient progress and changes as appropriate. The supervising physician and the medical director of the health and medical division reserve the right to ask the mid-level provider to turn care of a particular patient over to them at any time. The supervising physician and the medical director reserve the right to turn care of a particular patient over to a mid-level provider at any time.

Regular case management meetings will occur to staff cases and determine appropriate provider care.

It is the responsibility of the supervising physician to ensure time is spent at least every other week to review cases and consult with the mid-level providers supervised. It is the responsibility of the program manager to ensure that the program schedule allows for this time. It is the responsibility of the mid-level provider to consult the supervising physician or the HMD medical director or other CIHA physician(s) whenever a question regarding care arises or when a patient presents with issues outside the scope of mid-level provider care.

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Case Management Responsibilities

PURPOSE: To clearly identify case management roles and responsibilities; to ensure continuity of care; to ensure compliance with ADA and provider standards

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 1/04

DISTRIBUTION: CDP Staff

POLICY: The RN/Case Manager and/or RN/Nurse Educator assigned to each team will be responsible for initiating and maintaining a structured case management system for each patient assigned to each team.

The goals of case management for the Cherokee Diabetes Program are:

  1. The timely completion of routine patient wellness activities facilitated by the case manager. These activities include, but are not limited too:
    1. PAP tests
    2. Mammograms
    3. PSA screening
    4. Hemocult screening/rectal exams
    5. Retinopathy screening
    6. Dental screening
    7. Diabetic Foot Exams
    8. Immunizations
    9. Most recent EKG
    10. Colo-rectal cancer screening

Q-man searches will allow for large searches to see what patients are in need of screening.

  1. Diagnostic data (labs, pathology, radiology, etc.) will be directly reviewed by providers with the necessary feedback and decision making discussed with case managers
  2. Serial hemoglobin A1c values will be monitored closely. Changes will trigger discussion with the medical provider (and care team if appropriate) and the collaborative formulation of a treatment and education plan.
  3. The case manager is the point person/liaison who can expediently address and triage patient issues while minimizing distractions to the medical provider. With the exception of medication refills, the liaison acts as the first point of contact for patients, triages patient needs, and manages patient issues if appropriate and within the scope of the case manager, and prioritizes issues that must be addressed by the medical provider.
  4. The case manager will optimize efficiency and productivity of patient/ medical provider visits by :
    1. Maintaining an efficient flow of patients with the medical provider on visit days.
    2. Checking provider messages and triaging issues.
    3. Preparing for patient visits by having pre-visit labs, outside consultation reports, and radiology reports pulled and ready for the provider.
  5. The case manager will document all case manager/education related patient encounters outside of the routine medical visit on the PCC plus form. This documentation will be co-signed by the medical provider to
    demonstrate care continuity and ensure communication of information.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Critical Laboratory Values

PURPOSE: To ensure that critical laboratory values are followed-up immediately

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 05/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Any critical lab value will be addressed immediately when it is reported to the CDP by the laboratory.

PROCEDURE:

  1. When a critical laboratory value is called to the CDP, it will be reported to a licensed staff member immediately.
  2. Critical values will routinely be reported to the program manager. If she or he is not available, the value will be reported to one of the case managers/educators. If none are available, the value will be reported to the LPN.
  3. The medical record will be pulled and a PCC form generated.
  4. The licensed person who received the value will document this on the PCC and the ordering provider will be notified. In the event that the ordering provider is not available the results will be discussed with another provider and that provider will become the managing provider of record for the incident.
  5. The ordering or managing provider will document any actions on the PCC.

 

 



Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Diagnostic Criteria for Diabetes, IFG, and IGT

PURPOSE: To establish a consistent, scientifically based protocol for diagnosis of
Diabetes Mellitus, IFG, or IGT.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: prior to 06/02

DATE REVIEWED OR REVISED: 03/04

DISTRIBUTION: CDP Staff

POLICY: The “Standards of Medical Care for Patients with Diabetes Mellitus”1
published by the American Diabetes Association is the scientific benchmark
for diagnosing diabetes, IFG, or IGT.

The following criteria are used for the diagnosis of diabetes:

Symptoms of diabetes and a casual plasma glucose > 200mg/dl. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. Diabetes may be diagnosed in any of 3 ways-BUT EACH OF THEM MUST BE CONFIRMED ON A DIFFERENT DAY BY ANY OF THESE SAME 3 MEASURES:

  1. Symptoms of DM plus a casual plasma glucose =200 mg/dl
  2. FPG =126 mg/dl
  3. OGT 2-hour glucose of 200mg/dl

In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.

Hyperglycemia not sufficient to meet the diagnostic criteria for diabetes is categorized as either IFG or IGT. Criteria for diagnosis of IFG is a fasting plasma glucose (FPG) of
>100 mg/dl and =125mg/dl. Criteria for diagnosis of IGT is 2-hour plasma glucose >140mg/dl and <200mg/dl or 140mg/dl – 199mg/dl as an oral glucose tolerance test (OGTT)


1. “Standards of Medical Care for Patients with Diabetes Mellitus.” Diabetes Care, 01/04. American Diabetes Association.

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: DNKAs - (No shows/no calls)

PURPOSE: To ensure continuity of care and follow-up; to ensure documentation of patient compliance with scheduled appointments

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 12/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Patients who fail to show for scheduled appointments will be rescheduled and followed-up. Scheduled appointments for which the patient does not show, does not cancel, and/or does not reschedule, will be documented in the medical record and in RPMS.

PROCEDURE:

  1. Mark DNKA’s down on the patient chart (DNKA form)
  2. The Administrative Assisitant will document “DNKA” in the patient chart and document in RPMS.
  3. The Administrative Assistant will generate a letter and arrange mailing.
  4. The “case managers” will attempt phone contact with patient.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: EKG Interpretation

PURPOSE: To ensure the accurate and timely interpretation of EKGs; to ensure
appropriate patient management

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 05/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: All EKGs will be reviewed at the point in time when they are performed followed by immediate patient management if indicated.

PROCEDURE:

  1. EKGs will be reviewed only by a physician or mid-level practitioner.
  2. If the mid-level practitioner does not feel comfortable interpreting the EKG, the CDP physician will be consulted at that time.
  3. If the CDP physician is not available, the mid-level is to try and contact the medical director of HMD. In this persons absence, the CIHA officer of the day will be consulted.
  4. The patient is not to leave until final resolution regarding the EKG has been reached.

 


 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Erythropoietin (Epogen) Dosing Protocol

PURPOSE: To ensure consistency in the administration of Epogen; to ensure that
administration is consistent with any change in patient dynamics.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The CIHA Erythropoietin Dosing Protocol will be followed.

PROCEDURE:

  1. Follow the attached protocol. In addition to the protocol, pay careful attention to:
    1. The patient must have a baseline ferritin, transferring % saturation, vitamin B-12, Folate, reticulocyte count, and CBC with differential prior to starting therapy.
    2. Prior to each administration, the patient must have a calculated MAP as well as a hematocrit.
      1. MAP = ((Systolic B/P – Diastolic B/P)/3) + Diastolic Pressure.
      2. If >150 – hold the dose and refer to a provider.

 

 



Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Hours of Operation

PURPOSE: To communicate hours of operation to patients and the public.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Program hours of operation are from 7:45am – 12:00noon and
12:45pm – 4:30pm Monday – Friday. Wednesday morning and Friday afternoon are designated administrative times.

PROCEDURE:

  1. The program hours will be posted on the door.
  2. The program hours will be stated on the main telephone message.
  3. Any exceptions to the hours (i.e. holidays, Tribal events) will be posted on the door and stated on the telephone message by the receptionist.

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Immunizations

PURPOSE: To ensure that all patients stay current on recommended immunizations
STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: It is the policy of the Cherokee Diabetes Program to adhere to immunization programs, practices, and policies promulgated by the state of North Carolina, Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices, and the National Childhood Vaccine Injury Act of 1986. All CDP patients will be screened specifically for pneumococcal, tetanus, hepatitis B, and influenza immunization status and offered the vaccine if appropriate. This policy serves as a standing order or protocol authorizing the LPN or RNs to order and administer the immunization according to the following guidelines:

Pneumococcal (Pneumovax) Vaccine:
Indications:

  1. Diagnosis of diabetes
  2. 65 years of age or greater who have not been immunized or received immunization greater than 5 years ago.

Contraindications:

  1. Previous severe reaction to the vaccine
  2. Women who are pregnant should consult their physician prior to immunization.


Patient Education:

  1. A copy of the attached CDC-produced patient information will be provided to the patient.
  2. If the patient cannot read or understand the literature, the provider administering the vaccine will verbally provide information and answer any patient questions.

Administration:

  1. 1 dose of Pnueumococcal Polysaccharide Vaccine


Influenza Vaccine:
Indications:

  1. All patients

Contraindications:

  1. Allergy to eggs
  2. Previous severe reaction to the influenza vaccine
  3. History of Guillan Barre Syndrome
  4. Current respiratory illness

Patient Education:

  1. A copy of the attached CDC-produced patient information will be provided to the patient. This information is reproduced annually.
  2. Patient must sign form acknowledging receipt of educational material and review of contraindications.
  3. If the patient cannot read or understand the literature, the provider administering the vaccine will verbally provide information and answer any patient questions.

Administration:

  1. 1 dose

Special Note: The vaccine will only be administered as quantities are available in the fall of each year. In vaccine shortage situations, patients with the most complications and highest risk of contracting influenza will receive first priority.

*Diabetes patients are not candidates for nasal Flu-Mist vaccine due to the fact that the nasal spray is a live virus.

Tetanus and Diphtheria Vaccine (Td):
Indications:

  1. All patients 7 years of age or older
  2. Any patient who has not gotten at least 3 doses of any tetanus and diphtheria vaccine (DTP, DTaP, or DT) during their lifetime should do so using the Td.
  3. Any patient who has received the third dose of any tetanus and diphtheria vaccine during their lifetime should receive a Td booster dose every 10 years.

Contraindications:

  1. Any history of severe allergic reaction or other problem with any prior tetanus and diphtheria vaccine
  2. Currently has a moderate or severe illness
  3. Pregnancy

Patient Education:

  1. A copy of the attached CDC-produced patient information will be provided to the patient.
  2. If the patient cannot read or understand the literature, the provider administering the vaccine will verbally provide information and answer any patient questions.

Administration:

  1. 1 dose of Tetanus and Diphtheria (Td) vaccine.

Hepatitis B Vaccine
Indications:

  1. Patients receiving hemodialysis.
  2. Patients actively working in an environment where they are at risk for exposure who request the vaccine

Contraindications:

  1. Previous severe reaction to this vaccine or to any of its components.
  2. Moderate or severe acute illness

Administration:

  1. 2 doses 1 month apart
  2. A third dose 5 months later

Documentation of Immunizations:

  1. Each immunization will be documented on the PCC form including:
    1. Vaccine administered
    2. Dose of vaccine administered
    3. Site of administration
    4. Time of administration
    5. Lot #
    6. Provider initials
  2. Refusal of immunization will be documented
  3. Patient Education will be documented according to IHS patient education codes:
    1. “IM” – immunization
    2. “I” for Immunization Information and/or “L” for Patient Information Literature
    3. Level of understanding
    4. Provider code
    5. Duration of Teaching
    6. Patient will be given written documentation of vaccine time line and when to return.

Source:
CDC. Use of Standing Orders Programs to Increase Adult Vaccination Rates. MMWR.
Vol. 49:RR-1. April 24, 2000
CDC. Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Vol.46:RR-8. April 4, 1997
CDC. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Vol 48: RR-4. April 30, 1999
CIHA Immunizations Policy and Procedure.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Inclement Weather Protocol

PURPOSE: To communicate program hour modifications clearly between staff and patients in the case of inclement weather.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 01/03

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

PROCEDURE:
The following procedure will be followed in the event of inclement weather:

  1. When weather predictions are for inclement weather, the receptionist or administrative assistant will notify patients who are scheduled on the applicable day(s) and remind them to check with the CDP prior to leaving for their appointment.
  2. CDP staff should notify the program manager at home on the affected day(s) if not able to travel due to inclement weather.
  3. In the event that providers are not able to travel to the office and/or in the event that administrative leave is granted by the Chief and the program is formally closed, the program manager will place a voice mail message on the CDP main telephone in order to notify patients.
  4. In the event that inclement weather strikes suddenly necessitating that staff leave work early for safe travel, the administrative assistant or receptionist will make every effort to notify remaining patients and will place a sign will be posted on the CDP door.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Inpatient Tracking

PURPOSE: To ensure that diabetic patients admitted to the CIHA receive continuity of care and consultation (if needed) from the CDP.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 01/03

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The MSW from the CDP will attend CIHA inpatient rounds. The MSW will serve as a liaison between the medical staff and the CDP facilitating any clinical issues that arise. The goals of this experience are:

  1. Note all patients admitted with a diagnosis of diabetes
  2. Providing notification to CDP staff of patient admissions
  3. Fill out a form indicating patient name, admission date, admission diagnosis,
    admitting provider, issues of concern.
  4. Form is returned to receptionist who will pull chart, attach form and place in the appropriate case manager/educator box.
  5. Make a social visit to the patient. Discuss with them how they are feeling, how they are managing their stress, any specific issues that they have, and their plans for follow-up after discharge, any family issues. This visit should be documented as a diabetes support advocate visit and placed in the patient’s chart.

Cherokee Diabetes Program Diabetes Support Advocate Inpatient Contact Log

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Kidney Clinic Group Medical Model

PURPOSE: To establish guidelines for managing this special, group medical model

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Any patient with creatinine clearance < 50 and/or serum creatinine > 2.0 should be referred to the kidney clinic. The clinic meets at least once every 6 weeks. Staff members involved include:

  • Supervising MD – oversees the assessment of all patients and medication refills.
  • Mid-level practitioner – assists the supervising MD as directed
  • RN Case Manager – coordinates the entire clinic by ensuring that labs are ordered and matched with the patient chart, that the meeting room is prepared, that patient charts are available, that any situations that arise are handled, and that patient charts are routed appropriately at the end of clinic.
  • Educator – ensures that an appropriate snack is provided for the group, arranges and coordinates patient education.
  • Screener(s) – screens all patients prior to the clinic.
  • Pharmacist (if available) – enters prescriptions into the RPMS system.
  • Physical Therapist (if available) – leads the group in appropriate, low impact stretching and physical activity exercises.
  • Wound Care Technician (if available) – provides foot checks or exams to all patients.


Upon initial kidney clinic and/or nephrology referral, all patients will have the following laboratory studies completed

  • CMP - Comprehensive Metabolic Panel (glucose, BUN, creatinine, total bilirubin, AST/ALT, albumin, calcium, alkaline phosphatase, Na, K+, Cl, total protein)
  • Urinalysis
  • Hemoglobin A1c
  • Care Panel
  • CBC
  • TSH
  • Serum Magnesium
  • Serum Phosphorus
  • PTH intact
  • Iron Panel
  • Serum Ferritin
  • Serum Erythropoietin
  • Hepatitis Panel
  • Urine Protein/Creatinine Ratio
  • Creatinine Clearance

All patients will have the following minimum laboratory studies completed for each clinic:

  • Hemoglobin A1c
  • Renal Panel

All patients will have the following laboratory studies completed at least every 6 months:

  • Hemoglobin & Hematocrit
  • CARE panel
  • Creatinine Clearance

The laboratory studies required will be requisitioned and mailed to patients with their reminder letters.

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Laboratory Orders

PURPOSE: To ensure that laboratory tests are drawn in conjunction with patients next visit

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 07/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Laboratory tests will be ordered at the previous visit and will be entered into RPMS under “Other”. When letters of appointment are mailed it will be indicated on the letter whether labs should be drawn the day before or can be drawn the day of appointment. Also, it will indicate whether the patient should be fasting or not.

PROCEDURE:

  1. At the end of the patient encounter, the medical provider transcribes laboratory tests that the patient should have performed for their next visit.
  2. The receptionist enters the orders into the RPMS system including special instructions on fasting.
  3. The pre-appointment letters will be sent out one week prior to appointment indicating what labs will be drawn and whether patient is fasting or not.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Laboratory Reports

PURPOSE: To ensure that laboratory reports are managed in a timely and appropriate
manner.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 05/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: All laboratory reports (work copies) will be reviewed and signed (initialed)by the ordering medical provider before they are filed or destroyed. This includes routine reports that are ordered by case managers/educators following protocol.

PROCEDURE:

  1. Lab reports, including routine blood work, pathology and culture reports will be picked up daily in the lab at CIHA.
  2. Front Office staff are responsible for pulling charts and attaching reports to front of chart.
  3. Charts are placed in the appropriate provider’s box up front.
  4. The medical provider will review labs.
  5. If the report warrants a change in patient management, a PCC form will be generated, and the change/patient consultation will be documented on the PCC by the provider or case manager.
  6. the provider or case manager is responsible for timely feedback (within 24 hours) to the patient for lab reports that come back abnormal.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Laboratory Tests – Protocol for Routing Ordering

PURPOSE: To establish a protocol for ordering laboratory tests to be followed by educators/case managers that is consistent with program standards of diabetes care.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 06/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The Cherokee Diabetes Program follows the recommendations of the American Diabetes Association (ADA), the Indian Health Service (IHS) National Diabetes Program, and pharmaceutical manufacturer clinical recommendations as a foundation for the clinical management of patients with diabetes. The following protocol is based upon those recommendations.
Protocol:

  1. A1C if appointments are 2 months or greater apart or sooner at the discretion of the provider.
  2. Urinalysis every appointment for females, every six months for males.
  3. If the patient demonstrates proteinuria, a creatinine clearance and 24 hour urine protein level should be performed at least annually.
  4. Serum ALT, if the patient is on Avandia, drawn at baseline (prior to initiating the medication) then every 2months for first year, and every 6 months thereafter, more frequently if there is an elevation in liver function tests. Serum ALT and AST levels should be drawn at baseline (prior to initiating the medication), then every 3 months for the first year then every 6 months for each year thereafter if the patient is on a Statin, Gemfibrozil, and/or Niaspan,
  5. Serum creatinine annually.
  6. If the patient is on an ACE inhibitor, HCTZ, Furosemide, and/or Metalazone, a serum potassium should be drawn at least every 6-12 months and depending on previous values and/or increases in dosage.
  7. Urine microalbumin annually if urinalysis is negative for protein.
  8. Urine creatinine clearance initially and annually when proteinuria or microalbuminuria are present.
  9. CARE panel at least annually, depending on values and/or medication adjustments.
  10. PSA annually for males 50 years of age and older; earlier if there is a history of prostate abnormalities.
  11. TSH upon initial diabetes diagnosis; at least annually if hypothyroid and taking Synthroid – more frequently if uncontrolled on Levothyroxine, and annually in females 40 years of age or greater

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Medication Adjustments

PURPOSE: To ensure that medication adjustments are accurately accomplished

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The physician and/or mid-level provider retains ultimate authority and responsibility for medication adjustments. All medication adjustments must be signed and approved by the physician or mid-level provider.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: New Patient Diagnosis/Screening

PURPOSE: establish protocol of treatment for new patients

STAFF GOVERNED BY THIS POLICY: CDP staff

EFFECTIVE DATE: 4/04

DATE REVIEWED OR REVISED:

DISTRIBUTION: CDP Staff

POLICY: New patients to CDP for new diagnosis of Diabetes Mellitus shall have specific tests done prior to provider seeing the patient.
The following shall be obtained:

  • Fasting venipuncture draw for CARE (lipids) panel,
  • Fasting venipuncture for serum glucose
  • Urinalysis

This policy serves as a standing order for the above tests to be drawn and sent to lab. PROVIDERS NEED TO CO-SIGN ORDER and place appropriate DX for labs.

When at all possible try and have patient into clinic prior to actual provider visit for labs so that results are available when provider sees patient.

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Nursing Procedures

PURPOSE: To establish a protocol implementation of basic nursing procedures that is scientifically and research based, and is used consistently as a baseline by all nursing care providers.

STAFF GOVERNED BY THIS POLICY: CDP Nursing Staff

EFFECTIVE DATE: 01/03

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

REFERENCE: Handbook of Nursing Procedures. 2001. Springhouse Corporation


POLICY: The Cherokee Diabetes Program nursing staff will utilize the Handbook of Nursing Procedures as a baseline for performing basic nursing procedures including, but not limited to:

  • Vital sign assessment
  • EKG performance
  • Pulse oximetry measurement
  • Intramuscular and subcutaneous injections
  • Oral medication administration
  • Basic nursing assessment


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Patient Education

PURPOSE: To define the patient education process; to ensure continuity of care; to ensure compliance with ADA and provider standards.
STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

REFERENCES: Life with Diabetes: A Series of Teaching Outlines by the Michigan
Diabetes Research and Training Center. 2000. American Diabetes
Association, Inc. 2nd. Ed
Library of Patient Handouts for Diabetes Education. 2002. Milner-
Fenwick, Inc. Volume 1.
Patient Teaching Reference Manual. 2002. Springhouse Corporation.
HIS Diabetes Curriculum, 2003.

POLICY: The educator assigned to each team will be responsible for performing a needs assessment with the first patient visit as part of establishing the plan of care. Education needs will be assessed and education provided with each patient encounter. Learning needs will be assessed using the diabetes health assessment, specific questions submitted by the patient, with pre-tests (verbal or written) on specific topics, or areas identified by providers during the course of providing care. The following mechanisms will be utilized to provide patient/family education:

  1. 1:1 discussion of concepts
  2. Demonstration
  3. Literature/Handouts
  4. Audiovisuals
  5. Internet/web based resources
  6. Focused classes/seminars
  7. Group Process

Patient/family learning will be evaluated by:

  1. Return discussion of concepts
  2. Demonstration
  3. Patient/family evaluation of classes/seminars for accomplishment of learning goals and satisfaction with information presented.

Learning Needs Assessment:
The educator will assess learning needs based upon the following areas:

  1. Diabetes Overview
    1. Verbalization of general diabetes facts
    2. State own type of diabetes
  2. Self Monitoring of Blood Glucose (SMBG):
    1. Demonstrate the use of glucose monitor
    2. Log blood sugar results
    3. Describe safe lancet disposal
  3. Acute Complications:
    1. State causes, signs & symptoms, prevention & treatment of hypoglycemia.
    2. State causes, signs & symptoms, prevention & treatment of hyperglycemia.
    3. State when to call the health care provider with out-of-range results
  4. Chronic Complications:
    1. State understanding of the prevention, detection, and treatment of chronic complications
    2. State benefits, risks, and management options for improving blood sugar control.
  5. Foot, skin, and dental care:
    1. State importance of daily foot care & exam
    2. State signs & symptoms of potential foot problems and when to call the provider
    3. State the need for appropriate dental care.
  6. Medications:
    1. State correct use of oral agents
    2. Correctly draw up and administer insulin
      c. State understanding of insulin action
    3. Describe safe needle disposal
  7. Psychosocial:
    1. Identify diabetes management as a source of stress
    2. Verbalize feelings about diabetes
    3. Identify family/significant other role in managing diabetes
  8. Exercise and physical activity:
    1. State importance/benefits/barriers of exercise
    2. State relationship between exercise, food, medication, and blood glucose.
    3. Discuss the appropriate amount of exercise.
    4. Discuss issues related to medications and exercise
  9. Nutritional Management:
    1. State relationship of CHO and blood sugar levels
    2. State understanding of diabetes meal planning and spacing of meals and snacks
    3. State understanding of food label reading
    4. Identify healthy choices that can be made
  10. Preconception, pregnancy, and gestational care:
    1. State relationship between glucose control pre and post conception on pregnancy and outcome
    2. Explain risk of maternal and fetal complications due to diabetes.
  11. Lifestyle changes:
    1. State benefits of making lifestyle changes and identify behavior(s) to change.
    2. Identify risk factors that interfere with health
    3. Develop problem-solving strategies to make changes and reduce risk factors.
  12. Health & Community Resources
    1. Verbalize the need for healthcare follow-up
    2. State one appropriate community resource

The provider will utilize routine patient visits to identify education needs by: (Bold type identifies potential education needs/referrals that can be triggered)

  1. Assessing, in the patient's own words, subjective data, statements regarding how that they are feeling, and/or any verbalized concerns or issues. (Knowledge deficit regarding stress management, effective coping strategies; Knowledge deficit regarding new symptoms and the need for those to be Addressed; may trigger referral to the diabetes support therapist.
  2. Assessing the patient's pattern of self-blood glucose monitoring and average value range. (Knowledge deficit regarding self blood glucose monitoring patterns)
  3. Assessing the patient's adherence to the prescribed medication regimen with specific focus on diabetes medications; the patient’s medication regimen should be documented on the PCC. (Knowledge deficit regarding when and how medications should be taken; knowledge deficit regarding relationship between blood glucose levels and medication regimen; may trigger referral to a pharmacist)
  4. Assessing the patient's usual dietary regimen including:
    1. appetite quality
    2. usual eating patterns (i.e. time of day0
    3. usual food choices
    4. usual food preparation methods
    5. food intolerances
      (Knowledge deficit regarding the relationship between eating patterns and blood glucose levels; knowledge deficit regarding low fat and low carbohydrate food choice selections and/or food preparation methods; may trigger need for referral to nutritionist)
  5. Assessing the patients usual physical activity regimen including:
    1. type of exercise (if any)
    2. usual duration of exercise
    3. perception of exercise effects (i.e. increased energy, fatigue)
    4. symptoms associated with exercise (i.e. chest pain, shortness of breath, faintness, blood glucose variations)
      (Knowledge deficit regarding the relationship between physical activity and blood glucose levels, cholesterol and triglyceride levels, blood pressure, and vascular problems; knowledge deficit regarding how to develop an individualized physical activity routine without complications such as angina, cramping, shortness of breath, etc.; may trigger referral to a nutritionist or fitness counselor)
  6. Assessing the patient's vital signs (including weight, hemoglobin A1C, oxygen saturation, and last menstrual period if applicable) and noting abnormalities to the medical provider.
    (Knowledge deficit regarding normal parameters for weight, blood pressure, peak flow, heart rate and their relationship with diet, exercise and stress; knowledge deficit regarding normal menses; may trigger referral to diabetes support therapist; may trigger referral to nutritionist and/or fitness counselor; may trigger referral to women's wellness educator.
  7. Assessing use of tobacco and alcohol products.
    (May trigger referral to diabetes support therapist for tobacco cessation/substance abuse recovery)
  8. Performing diabetic foot checks with each visit; performing diabetic foot
    exams at least annually; noting any subjective concerns that the patient has.
    (Knowledge deficit regarding standard diabetic foot care)
  9. Asking the patient if he/she has any special concerns that they would like to
    Discuss including the effects of diabetes on sexuality, stress management, family/social support (Knowledge deficit regarding sexual dysfunction; coping skills; may trigger referral to diabetes support therapist.

Provision of Education:
The Life with Diabetes curriculum will be used as the standard reference for diabetes-related lesson plans. The AADE Library of Patient Handouts for Diabetes Education. will be used as a standard reference for diabetes related patient handouts in addition to other materials deemed appropriate by the educator. The Patient Teaching Reference Manual and IHS Patient Education Codes will be used for non-diabetes related teaching needs.


Evaluation & Documentation:
The educator will document all education using the IHS approved education codes. Any education not included in the IHS approved education codes will be documented as a narrative on the PCC. Standard documentation of patient education is as follows:

Education Topic Understanding Provider Time

Education
Topic
Understanding
Provider
 Time
DM
LA/1
G  F  P  R                    GRP
693
15
DM
 FTC/2
G  F  P  R                    GRP
693
5

 

Education: Diabetes, tobacco, etc, according to IHS codes
Topic: specific topic/pre-teaching level where:
0 = Not applicable
1 = Needs instruction
2 = Needs review/assistance
3 = Verbalizes/demonstrates competency
Understanding:
G = Good
F = Fair
P = Poor
R = Refused
GRP = Group
Provider: Initials or code
Time: Duration of teaching in minutes

Specific patient goals and action steps will be documented on the PCC+ form. Providers will refer to any goals/actions established during the prior visit with each subsequent visit and document the level of goal completion.

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Patient Satisfaction Surveys

PURPOSE: To assess patient satisfaction of the program services.
STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 07/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The CDP will use the attached patient satisfaction survey form to assess patient satisfaction with the program.

PROCEDURE:

  1. A patient satisfaction survey will be included in all pre-appointment letters in March, June, September, and December (quarterly).
  2. Patient satisfaction surveys will be available in the program at all times.
  3. A secure box in the CDP lobby will be available to confidentially collect surveys.
  4. Survey results will be used to enhance and/or change program services.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Patients Requiring Hospital Admission or Out-of-facility Transfer

PURPOSE: To ensure that patients who require hospital admission or transfer out of the facility receive stabilizing treatment that is appropriate, timely, and compliant with the EMTALA.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

PROCEDURE:

  1. If a patient requires hospital admission, the CDP should follow the following procedure:
    1. The CDP supervising MD should be notified immediately. If this person is not available, the HMD Medical Director should be notified. If this person is not available, the CIHA officer of the day should be notified.
    2. Patients who are unstable or potentially unstable should be transported to the emergency department via ambulance. Tribal EMS should be notified.
    3. The RN/ Case Manager or the provider will contact the emergency and notify them of the patient being transported. PCC form should be faxed to the emergency room.
    4. If the patient is stable and not requiring oxygen, cardiac monitoring, intravenous fluids/medications, patient may be transferred to the hospital by family. In this case the option of ambulance or family transport needs to be discussed with the patient and family.
    5. UNDER NO CIRCUMSTANCES IS A PATIENT TO TRANSPORT THEMSELVES (BY THEMSELVES) TO THE EMERGENCY ROOM.
  2. If a patient requires out-of-facility transfer (i.e. to Mission St.Joseph’s), the patient must be transported to the emergency department to await transport to ensure that the patient is monitored appropriately. Report will be given to the emergency department staff by the CDP staff.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Plan of Care

PURPOSE: To ensure multidisciplinary development of the patient plan of care; to ensure that all subjective and objective factors are considered in developing the plan of care.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: prior to 11/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The diabetes health assessment will be completed on each new patient and will be used to identify needs based upon patient perceptions, support systems, barriers and constraints, coping skills, socioeconomic status, and past medical history. The care team will establish the plan of care based upon this information, the results of diagnostic testing, and physical assessment/examination. The diabetes support therapist and other sources will be consulted as needed.

The physician or mid-level provider for each team maintains primary responsibility for the plan of care of each patient on that team. The program supervising physician and/or health and medical division medical director oversees the plan of care for all patients in the program.

The plan of care will be reflected in the PCC+ documentation for each patient encounter.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Pre-appointment Letters

PURPOSE: To ensure a reliable mechanism for notifying patients of their
appointments.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 07/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: A pre-appointment letter will be mailed to each patient at least one week of their scheduled appointment. The receptionist generates these letters and addresses in the letter the necessary lab work that will be done, fasting status and other information needed for the appointment. If the receptionist is not available then the administrative assistant will do this task. Letters are to be generated every Friday afternoon.

PROCEDURE:

  1. Sign on to the RPMS system.
  2. Enter the scheduling package.
  3. Under “SCR”, to “PL” – print scheduling letters.
  4. Enter “P” for pre-appointment as the type of letter to print.
  5. Enter “yes” when asked “print letter assigned to the clinic(s)
  6. Enter “CIHA” for division.
  7. For the next prompt, enter “P” if you want to generate a letter for a specific patient or “C” if you want to generate a letter for a specific clinic.
  8. Enter patient or clinic
  9. Enter date range
  10. Print letters to the central diabetes printer
  11. Place in the outgoing mail box for the administrative assistant to mail.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Prescription Refills

PURPOSE: To ensure that request for medication refills are handled in a timely
manner with minimal disruption to providers

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 06/02

DATE REVIEWED OR REVISED:

DISTRIBUTION: CDP Staff

POLICY: Medication refills will be accomplished using a PCC plus form and provider signature.

PROCEDURE:

  1. When a patient requests medication refills,
  2. Message is taken, placed on patients chart and placed in provider box.
  3. Provider is to review and make decision on refills.
  4. This will be conveyed to the case manager who will generate a PCC plus form.
  5. The patient must have a future appointment scheduled, and this must be documented on the PCC.
  6. The medication to be refilled is listed on the form, along with the quantity to be dispensed.
  7. The PCC is sent to the pharmacy.
  8. Patients requesting medication refill are to be notified of a 24-hour (business day) turn around on prescriptions and pick up. The only exceptions to this are life threatening medications which must be filled the same day.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Recurring Medication Orders

PURPOSE: To ensure that recurring outpatient medication orders are noted and
handled appropriately.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 06/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Recurring medication orders are to be recorded under the medication section of the PCC Plus form; medications administered following this protocol will be documented on a PCC for each visit.

PROCEDURE:

  1. The physician or mid-level practitioner writes the medication order under the
    medication section of the PCC-Plus encounter form and completes a “Recurring Medication/Treatment Order Form” (attached)
  2. The “Recurring Medication/Treatment Order Form” is given to the program LPN (if absent, the form is given to the program manager)
  3. The Program LPN initiates a “Recurring Medication Flow sheet” (attached) for the patient.
  4. With each patient visit, the nurse verifies the original medication/treatment order and the expiration date.
  5. The nurse administers the medication/treatment as ordered.
  6. The nurse documents the administration including the time, medication, dose, route, site, and response on the flow sheet.
  7. The original flow sheet is sent to medical records until the next patient visits.
  8. The nurse copies the flow sheet each visit for the diabetes program record.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program


SUBJECT: Requests for Time Off

PURPOSE: To ensure the coverage of patient needs and the department.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Patient-care needs will receive first priority when employee requests for time
off are considered.

PROCEDURE:

  1. Requests for time off are directed to the program manager.
  2. Employees who wish to request several days (i.e. more than 2 days) at one time should give at least 4 weeks notice.
  3. “Single day” requests will be considered based upon the activity in the department for that day. (Tribal policy is 3 days notice)
  4. When two or more employees request time off at the same time, approval will be granted for the request submitted first.
  5. Once the request is approved, the employee must submit a leave form to the program manager.
  6. Except for emergency situations, requests for several days at one time will not be approved if the request is not submitted in advance of 4 weeks.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Safety/Emergency Preparedness/Infection Control

PURPOSE: To establish safety, emergency preparedness, and infection control policies that are consistent with the OSHA and HMD.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The CDP will follow the safety, emergency preparedness, and infection control policies and procedures as outlined by the HMD and OSHA. The OSHA safety manual and MSDS for materials used specifically in the CDP will be maintained in an area accessible to all staff (Program Managers Office) at all times. Employees may also access all safety and infection control policies on the CIHA intranet or HMD website.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Scheduling

PURPOSE: To ensure that clients are scheduled with the appropriate provider and that
labs are ordered prior to the visit.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 05/03

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY:

  1. Except in certain circumstances, patients will be scheduled with the same provider for each visit.
  2. The “Other Info” feature in the RPMS scheduling package will be used to communicate any comments pertinent to the patient visit. Ex: labs for next visit and any other instructions for the next visit.
  3. The appropriate provider should be consulted to determine if any labs are needed when scheduling “add-ons”.
  4. The program nurse will be responsible for scheduling any new patients. He/she will review the health summary and, based on the caseload for mid-levels policy, determines the appropriate provider and any labs needed for the visit.
  5. New patients will be scheduled as follows:
    1. If the patient is a referral the patient will be directed towards a mid-level provider for initial visit and evaluation. After the initial exam the mid-level will determine whether the medical history and exam dictates the patient be assigned to a physician or a mid-level provider.
    2. If the new patient is a patient with no known diagnosis of Diabetes, but has a family history and is requesting evaluation, the patient will be set up an appointment with a nurse educator, dietician or CDE.

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Screening

PURPOSE: To evaluate vital signs; to identify potential problems

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 07/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: Vital signs will be taken initially on each patient who presents for a medical visit. Vital signs will be taken as appropriate for education visits. Vital signs are not necessary for diabetes support therapy visits.

PROCEDURE:

  1. Vital signs include:
    1. Finger-stick blood glucose
    2. Blood Pressure
    3. Temperature
    4. Pulse
    5. Weight
    6. Height
    7. Pulse oximetry on patients with respiratory complaints or known respiratory disease
  2. Vital signs will be documented along with the time and the provider number of the
    provider who performs the screening on the PCC form.
  3. Values out of the following ranges will be reported to the patient’s medical provider immediately:
    1. Finger-stick blood glucose > 400 or <60.
    2. Systolic blood pressure >200 or < 90; diastolic blood pressure >110
    3. Heart Rate >120 or < 50
    4. Respiratory Rate >40 or <12.
    5. Temperature > 102.5 For < 96.5 F
    6. Pulse oximetry < 95%

 

 



Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Security of Medical Records

PURPOSE: To ensure the confidential storage of patient medical records

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 07/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: All patient medical records, including electronic, will be handled and stored in a manner that ensures patient confidentiality.

PROCEDURE:

  1. All paper medical records will be stored and locked in the program medical records room in filing cabinets or in the provider’s office (locked cabinet) at the end of each working day.
  2. Medical records can be stored in provider boxes in front office as long as the windows and doors are locked at the end of each business day.
  3. During office hours, paper records will be secured by locking the program office when leaving for breaks and meetings. Otherwise, records will always be in the secure possession of authorized staff.
  4. The following people have keys to the medical record room: Program manager, Receptionist, Administrative Assistant, LPN.
  5. Electronic medical records will be secured by:
    1. All staff will have confidential access codes to the RPMS system.
    2. RPMS will only be accessed when a provider is actively searching for information; all staff will log off RPMS at other times.
    3. All staff will log-off their computers at the end of working hours and during breaks, lunch, and meeting times.

 

 

 

 

Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Sick Leave

PURPOSE: To ensure communication for the purpose of program scheduling when an
employee must be out sick.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 04/00

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: When an employee must miss work due to illness or family illness, the program manager and receptionist or administrative assistant are to be notified.

PROCEDURE:

  1. During working hours, the program manager should be notified.
  2. After working hours, a message should be left for the program manager at home or on cell phone and the program administrative assistant (in the event that the program manager is out).
  3. Request for sick leave pay must be submitted to the program manager when the employee returns on the appropriate form and attached to time sheet.

 

 

 


Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Diabetes Standards of Care

PURPOSE: To establish a protocol for managing and evaluating patients who have Diabetes based on ADA standards of care and HIS standards

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: Prior to 06/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: The Cherokee Diabetes Program follows the recommendations of the American Diabetes Association (ADA) and the Indian Health Service (IHS) National Diabetes Program as a foundation for the clinical management of patients with diabetes. “Standards of Medical Care for Patients with Diabetes Mellitus” and the “IHS Standards of Care for Patients with Type 2 Diabetes” are the scientific benchmarks of care for the Cherokee Diabetes Program. All medical providers, educators, and case managers are to be familiar with, and follow these guidelines as a minimum standard of care.

1. “Standards of Medical Care for Patients with Diabetes Mellitus.” Diabetes Care, 01/04. American Diabetes Association
2. IHS Standards of Care for Patients with Type 2 Diabetes. 04/02. IHS National Diabetes Program
3. Cherokee Health Services Algorithms for Lipids in Diabetes, Hypertension in Diabetes, Type-2 DM-Glucose Control

 

 

 

Health and Medical Division
Cherokee Diabetes Program


SUBJECT: Foot Care Standards

PURPOSE: To ensure that all providers are consistently following a scientifically based protocol for assessing and managing diabetic foot complications.

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 10/02

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff/WCTP

POLICY: All persons with diabetes will have a comprehensive foot examination at least annually and more often if warranted. All patients will have a foot check with each routine diabetes appointment. The foot check includes:

  1. Inspect between the toes. Inspect from toe to heel. Examine the skin for injury, calluses, blisters, fissures, ulcers, rashes or any unusual condition.
  2. Look for fragile, shiny, hairless skin (signs of decreased vascular supply)
  3. Feel for excessive warmth and/or dryness
  4. Inspect the nails for thickening, discoloration, ingrown corners, length, and fungal infection.
  5. Inspect hose or socks for signs of blood or other discharge.
  6. Examine footwear for torn linings, foreign bodies, abnormal wear patterns, and proper fit.
  7. Assess capillary refill and extremity pulse.
  8. Document findings on the PCC.

The comprehensive foot examination includes:

  1. patient history of:
    1. complaints of foot pain, skin breakdown, soreness, or other problems
    2. alcohol abuse
    3. smoking
    4. peripheral vascular disease
    5. occupation
    6. footwear
    7. previous amputation
  2. sensation testing using a standard 5.07 (10-gram) monofilament
  3. overall inspection:
    1. hygiene
    2. toe nail condition (i.e. hypertrophied nails)
    3. skin condition
    4. swelling and/or temperature changes
    5. redness of toes/feet
    6. location of calluses, corns, or blisters
    7. location of pre-ulcerative sites
    8. location, size, and depth of ulcers
  4. history of prior ulceration
  5. identification of foot deformities
  6. assessment of dorsalis pedal/posterior tibial pulses
  7. assignment of risk categories:
    1. Low risk (Category 0) - those patients with intact protective sensation (can feel the 5.07 monofilament) and no history of ulcers. These patients shall receive basic foot care education, nail care as needed/requested, and follow-up in one year or sooner if problems arise.
    2. High risk (Category 1, 2) – those patients without protective sensation (cannot feel 5.07 monofilament) with no history of ulcers, no foot deformities and/or decreased circulation. These patients shall receive basic patient education, referral to the wound care treatment and prevention program (WCTP), and follow-up every 3-6 months or sooner as needed.
    3. Highest risk (Category 3) – those patients without protective sensation, and with positive history of ulcers. These patients shall receive basic patient education and referral to WCTP for consultation regarding the need for monthly follow-up.

Referral to the WCTP is accomplished by placing a copy of the patient’s PCC in the WCTP box in the CDP. Referral to the CIHA physical therapy department is accomplished by calling the department and scheduling an appointment.

Determination of appropriateness for prosthetic shoes will be deferred to the wound care treatment and prevention program/physical therapy department as well as any patients requiring nail care, wound debridment, or callus care.

References:
Aberdeen Area Indian Health Service Standards of Diabetes Foot Care; February 1998.
Eastern Band of Cherokee Indians, Wound Care & Prevention Program Policies and Procedures



Health and Medical Division
Cherokee Diabetes Program

SUBJECT: Success Stories Program

PURPOSE: To ensure that that appropriate consent is received from patients who agree to participate in the Success Stories Program

STAFF GOVERNED BY THIS POLICY: CDP Staff

EFFECTIVE DATE: 01/03

DATE REVIEWED OR REVISED: 01/04

DISTRIBUTION: CDP Staff

POLICY: All patients who agree to participate in the Success Stories Program must provide written consent. The attached for should be used to collect the information to be shared with the public and to document patient consent. Consent must be witnessed by a provider.