Diabetes CCM Note

-Most recent labs: 

A1C 
Date:[date name="variable_1"
default="04/02/2021"] Result:
[text name="variable_1" default="%"] 
 
Urine microalbumin to creatinine ration 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="result"]

Estimated GFR: 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="result"]   

[comment memo="ACE include lisinopril, accupril, quinapril; ARB include losartan, candesartan, valsartan, olmesartan"]
[radio name="Q4" value="Patient is currently on an ACE/ARB|Patient is not currently on an ACE/ARB"]

LDL: 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="LDL"]  

[comment memo="High intensity statins are atorvastatin (Lipitor) 40 or 80mg or rosuvastatin (Crestor) 20 or 40mg"]
[radio name="Q5" value="Patient is currently on a high-intensity statin|Patient is currently on a low-intensity statin|Patient is not currently on statin therapy"]

-Prescribed medication regimen: 
[comment memo="Meal-time insulin, basal insulin, and sulfonylureas have higher risks of hypoglycemia than other medications"]
[checklist name="Q6" value="metformin|meal-time insulin|basal insulin|sitagliptin (Januvia)|GLP-1 agonist (Trulicity, Byetta, Victoza, Bydureon)|SGLT-2 inhibitor (Jardiance, Farxiga, Invokana)|sulfonylurea (glimepiride, glipizide, glyburide)|pioglitazone (Actos)"]

-Last eye exam: [date name="variable_1" default="date unknown"]

-Tobacco use: 
[radio name="Smoking" value="yes, not interested in quitting|yes, interested in quitting|no"]

-Immunization history: 
[checklist name="Vaccinations" value="Patient has received Pneumococcal (PCV-23) after age 65|Patient has received annual influenza vaccine"]

Recommendations:

Health Status: 
[comment memo="Healthy: Life expectancy >10y, age <75y\nComplex/Intermediate: 3+ chronic illnesses, 2+ IADL impairments, moderate cognitive impairment, age >75y\nVery Complex: SNF/LTC patient, end-stage COPD, dialysis patient, severe cognitive impairment, 2+ ADL impairments (most AL patients)"]
[select name="Q3" value="Healthy|Complex/Intermediate|Very Complex"]

[conditional field="Q3" condition="(Q3).is('Healthy')"]
A1C Goal: <7.5%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 90-130
Bedtime blood sugar goal: 90-150
Blood pressure goal: <140/80
Recommend statin therapy
Monitor LFTs and electrolytes every 6-12 months
Monitor urine microalbumin/creatinine ratio annually OR treat chronic kidney disease with ACE/ARB
Annual eye exams[/conditional]

[conditional field="Q3" condition="(Q3).is('Complex/Intermediate')"]
A1C Goal: <8.0%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 90-150
Bedtime blood sugar goal: 100-180
Blood pressure goal: <140/80
Recommend statin therapy
Monitor LFTs and electrolytes every 6-12 months
Monitor urine microalbumin/creatinine ratio annually OR treat chronic kidney disease with ACE/ARB
Annual eye exams[/conditional]

[conditional field="Q3" condition="(Q3).is('Very Complex')"]
A1C Goal: <8.5%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 100-190
Bedtime blood sugar goal: 110-200
Blood pressure goal: <150/90
Monitor creatinine at least every 6 months
Treat chronic kidney disease (if present) with ACE/ARB[/conditional]

Patient is due for the following:
[comment memo="If patient is due for any of the following, send a message to appropriate CC to have it ordered per protocol"]
[checklist name="Labs Due" value="Hemoglobin A1C|Urine microalbumin/creatinine ratio|Lipid panel|Complete metabolic panel|Vitamin B12 (if on metformin)|Eye exam|Pneumococcal vaccine|Influenza vaccine"]

Consider the following:
[comment memo="The following are recommendations to the provider.  Providers should document if there is a reason any of these are not done for inclusion in future care plans"]
[checklist name="Considerations" value="Prescribe an ACE/ARB|Prescribe a high-intensity statin|Switch to medications with a lower risk of hypoglycemia|Stopping some medications to avoid polypharmacy and hypoglycemia"]