Care Management: Identifies individual patients and plans, manages and coordinates care of those patients with diabetes. Develop and implement treatment plans and educational programs for patients, families and staff.
Care Delivery: 1:1 Direct patient care by providing education related to diabetes and the disease process; medication, diet and nutritional monitoring, prevention and care of complications, blood glucose monitoring and the techniques of self-monitoring and injection.
Assist patients in monitoring blood glucose for the purpose of medication control for both insulin and non-insulin dependent diabetics. Assess, monitor and implement treatment plans for patients at various stages of the disease.
General diabetes education:
-Difference between type 1 and type 2 diabetes and gestational diabetes
- Diagnostic criteria of Diabetes
- Symptoms and management of hyperglycemia and hypoglycemia
- Frequency of monitoring blood sugars in each specific type of diabetes
- Reviewing goal blood sugars and hemoglobin A1C values
- Reviewing treatment options of diabetes including lifestyle changes (dietary and exercise), oral medications, injectable medications
- Preventative care: eye exam, self – foot exams, dental exams
- Standards of DSME and MNT as per the American Diabetes Association Standards of Care
- Teaching patients how to carbohydrate count in preparation for pre-meal insulin therapy or insulin pump training
- Insulin Pump and sensor training (taught by Medtronic representative and trainers)
- Understanding and teaching patients on how to use insulin pens, syringes and the unique pens of GLP-1 agonists (non-insulin injectables)
- Understand and teaching patients how to use glucometers and lancing devices effectively
- Basic nutrition and diet goals specific to patients with type 1, type 2 or gestational diabetes
- Help with the frequent (every 2-4 weeks) management and care of gestational diabetics or pregnant patients with diabetes
Document assessments, interventions, and plan, including goals and proper ICD 10/CPT codes onto progress note within the EMR.
Triage patient phone calls, assist with rooming of patients, assist with standing orders, administer in office injections and infusions, assist with minor procedures and assist with managing prescription medications. Obtain prior authorizations for medications and procedures. Assist & manage follow-up care as requested by physician.
- Follow up with patients regarding blood sugars and diabetes management in between visits/over the phone.
People: Serve as a team lead and provide clinical resource and consultation to staff and physicians. Provide education to patients, caregivers and significant others. Maintains a level of communication that exceeds the person’s expectations in every encounter.
Regulatory: Works with PPM management team to comply with all established standards and regulations. Adheres to CPH and PPM policies and procedures, protocols, guidelines, etc.
Development: Works with PPM management team to resolve clinical issues (processes, performance, etc.) to identify opportunities for improvement.
Information Technology: To use the EMR as a patient registry, data input and retrieval to assist in patient-centered care (diabetic) and identify those most in need of intervention within the department. Coordinate with CPH/PPM Clinical & Health Informatics teams to improve performance, quality and patient outcomes/measures.
Other: Participates in ad hoc projects, as assigned.
Collaborate with PPM management team to address daily operational issues and solve problems to comply with the delivery of quality patient care. Integrates CPH mission and core values within the sites.
Works in collaboration with CPH and PPM departments as warranted.
Experience in diabetes education preferred.