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Care Management Plan: A Newly Diagnosed Diabetic Patient

1018 words - 4 pages

Type 2 diabetes mellitus is a growing disease in the United States. When developing a care management plan for new diabetic patient, several areas of education and resources should be considered. The purpose of this paper is to describe a hypothetical care plan for a newly diagnosed diabetic, including case management model used, initial and ongoing educational needs, and data collection and evaluation.

Case Management Model
Jane Doe has been diagnosed with type 2 diabetes postpartum. In order to provide continuous high quality care across the continuum, a diabetic case management plan will be needed. The plan will be the center of a diabetic case management team that adheres to a specific set of predetermined protocols and clinical care pathways (Cohen & Cesta, 2005). Members of the team will include a physician, nurse case manager, with the potential to consult a dietician, diabetic educator, and a social worker. This nonunit based multidisciplinary team approach ensures Jane Doe will receive care from experts in diabetes throughout her hospital stay as well as post discharge. The nurse case manager, along with the physician, will be responsible for developing an individualized plan of care. In addition, the nurse case manager will coordinate the recommendations from any additional team members that are consulted in a timely manner (Cohen & Cesta, 2005). The ultimate key to appropriate disease management is patient education; this is the tool that will empower Jane Doe to manage her diabetes successfully and to live a healthy, productive life.

Plan for Education
Initial
As with any new diagnosis, information about the disease process and treatment can be overwhelming for the patient. The early phase of educating Jane Doe about her new diagnosis will begin with simple basics. Initial education on hypoglycemia and hyperglycemia signs and symptoms as well as treatments will also be included. Several resources can be provided to Jane for future education. Beginning dietary education as well as the importance of a regular exercise program will be included prior to discharge. Because Jane has internet access the web site for the American Diabetic Association will be provided. The website will be able to provide information translated in Spanish and educational handouts written in Spanish to serve as additional reference guides. Because a new diagnosis of diabetes can be overwhelming an ongoing education plan will be implemented as well.

Ongoing
The medical clinic will serve as Jane’s primary source for treatment. A case manager will be assigned to follow up with the Jane over the next few months. She will be the coordinator between all the resources and patient. At the clinic information on other available community resources and support groups will be provided. Enrollment into an educational class on diabetes disease management will be provided. Jane’s individual education will include a review of her medications and...

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