Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module I: Diabetes and Glucose Monitoring.

Guidelines for Integrated Care (Psychiatric & Medical)

In the Community

Module I: Diabetes and Glucose Monitoring

ObjectivesAt the completion of Module I (Parts A and B),

participants will be able to:

Appreciate the need for integrated care in the mental health community to prevent premature deaths and increased disability from Diabetes Mellitus (DM) types I and II

Basic knowledge of DM (abnormal amounts of sugar in the blood)

Know the risk factors associated with DM

Objectives Identify patients with mental illness who have DM/risk

factors

Understand the concept of stages of change needed for appropriate interventions including use of tools for self-care, education and referral

Help those who are at risk for/diagnosed with DM in your caseload adequately communicate with their healthcare team for optimal care

Key Concept: Circulatory System

Controlling Blood Sugar: Balancing Act

Module I Part A:Importance of Integrated

Care

FactPeople with mental illness have a reduced life

expectancyThey die at least 20 years younger than the general

population from treatable physical Illnesses (such as DM)

Multi-State Study Mortality Data: Years of Potential Life Lost

Compared to the general population, persons with major mental illness typically lose 25 to 30 years of normal life span

Year AZ MO OK RI TX UT VA (IP

only) 1997 26.3 25.1 28.5 1998 27.3 25.1 28.8 29.3 15.5 1999 32.2 26.8 26.3 29.3 26.9 14.0 2000 31.8 27.9 24.9 13.5

(Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm)

Ohio Named 10th Fattest State: Persons with mental illness die even earlier in

Ohio

Severe Mental Illness (SMI) Morbidity and Mortality

Suicide and injury account for about 30-40% of excess mortality

60% of premature deaths in persons with schizophrenia are due to preventable (and costly) medical conditions with 20+ years of life lost

(URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm)

Physical Health Care for People with SMI is Poor

The CATIE (Clinical Antipsychotic Trials in Intervention Effectiveness) study investigators found that at the beginning of the study, participants had the following medical conditions:

88.0% had high cholesterol (dyslipidemia) 62.4 % had high blood pressure (hypertension) 30.2% had diabetes

And they were not being treated!

(Nasrallah HA, et al. Schizophr Res. 2006;86:15-22)

Metabolic Syndrome

What is Metabolic Syndrome?Metabolic syndrome is a group of conditions/factors

that when present in an individual significantly increase risks of heart disease and other acute and chronic medical conditions, including DM

What is Metabolic Syndrome?Abdominal obesity: waist circumference >40 inches in men and

>35 inches in womenAbnormal amount of fats in the blood (dyslipidemia):

High levels of LDL “bad” cholesterol that promotes build up of “plaque” in the arteries

Low levels of HDL “good” cholesterol that helps reduce the build up of plaque

High blood pressureTendency to form blood clots (prothrombotic state) Inability of the body to use insulin and blood sugar (blood

glucose) so blood glucose levels rise above normal DM

National Cholesterol Education Program: Diagnostic Criteria for

Metabolic SyndromeThree or more of the following:• Waist Circumference:

> 40 inches in men > 35 inches in women

• Triglyceride level>=150 mg/dl

• HDL “Good” Cholestero <40 mg/dl in men <50 mg/dl in women

• BP >=135/85

• Fasting (8-10 hours) blood glucose >=100 mg/dl

What is Glucose? A source of energy needed by the body for all of its

functions (digestion, movement, thinking, etc.) 

There is a range of blood glucose that is optimal for these bodily functions: 60-110 mg/dl Before meals less than 115 mg/dl Before bedtime less than 120 mg/dl

Glucose level is controlled by insulin that is secreted by the pancreas

Effects of Some Psychotropic Medications

Weight gain/obesity

Insulin resistance by impacting insulin receptor or post-receptor function abnormally high blood sugars and DM

Abnormal amounts of fat in blood (dyslipidemia)

Antipsychotic medications are associated with 2X the risk of sudden cardiac death

(Correll.MD et al, “Cardiometabolic Risk of Second-Generation Antipsychotic Medications During First-Time Use in Children and Adolescents”, JAMA, Oct., 2009)

(Ray et al, NEJM, Jan., 2009*)

Why is Diabetes Mellitus (DM) so important?

A common form of Metabolic Syndrome

Ranked as the 7th leading cause of death in the US

Estimated to affect 1 in 15 persons in the US

Persons with mental illness have a greater incidence of DM than the general population

Why is DM so Important?Untreated or mistreated DM can have severe

consequences in both the person’s mental and physical conditions

Mental Health clients have: 60-70% chance of suffering from mild to severe nerve

damage 65% chance of dying from heart disease or stroke increased chance of amputation, kidney failure and

adult blindness

Source: www.diabetes.org

What is DM?A chronic disease in which the body’s level of sugar

(glucose level in the blood) is not sufficiently regulated

In Type I DM, the body’s pancreas is not able to produce the needed level of insulin or any insulin at all resulting in a build up of sugar (glucose) in the blood

In type II DM, the body’s blood sugar (glucose) builds up because the body’s cells are not able to utilize insulin to metabolize its blood sugar

Risk Factors for Developing DMSedentary life style

Smoking

Nutritional intake

High BMI

Poverty

Genetic vulnerability

Risk Factors for Developing DMSide effects of medications (including some new-

generation anti-psychotics and anti-depressants)

History of Abuse (physical abuse: 26%-54, unwanted sexual touching:16%, forced sexual experience: 34%-69%)

Pregnancy

Diagnosis of Schizophrenia or Bi-polar disorder

DM: Racial Mis-representationRacial/Ethnic

BreakdownPrevalence of

Diabetes in the Community (%)

Racial/Ethnic Composition in the US

(%)

Source: Nat. Diabetes Assc. US Census (2008)

Native American/Alaska Native

16.5 0.7

African American 14.7 12

Hispanic/Latino American

10.7 16

Caucasian American 9.8 66

Asian American/Pacific Islander

7.5 3.7

Importance of ‘at-risk’ ClientsBefore people develop type II DM, they almost always have

"pre-diabetes” (blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes)

There are 57 million people in the United States who have pre-diabetes.

Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during pre-diabetes

How can DM be Prevented or Managed?Life style changes and self-monitoring:

Sedentary life style exercise regularly

Smoking decrease/stop smoking

Nutritional intake regulation of dietary intake

High BMI monitor weight and waist circumference

Poverty referrals, resources, benefits

How can DM be Prevented or Managed?

Life style changes and self-monitoring:

Side effects of medications (some new-generation anti-psychotics and anti-depressants) switching medications, lower doses

Diagnosis of Schizophrenia or Bi-polar disorder optimal treatment

Possibly testing blood sugar level 1-8x daily

Taking oral glucose lowering medication or insulin injections

Module I Part B:Implementing Guidelines for

Diabetes within Community-Based Mental Health Services

Together we can make a difference!

Trans-disciplinary approachManagement of co-occurring conditions needs to be

team based

The team includes the client and family members (where appropriate or possible)

Implementation of the guidelines discussed below to be coordinated between disciplines and specialties

Guidelines preferably provided/coordinated in one location of care, if possible

Role of Mental Health ProfessionalsMonitor and Assess (integrated treatment begins with the

clinicians awareness) for risk factors/current DM Initial assessment questions/observations of client Medical records Current medications

Monitor and Assess for DM related risk factors of certain psychotropic medications Weight gain:

• Zyprexa (olanzapine), • Clozaril (clozapine), • Seroquel (quetiapine), • Risperdal (risperidone), • Depakote (valproic acid), • Lithium (lithobid), • Elavil (amitriptyline), • Remeron (mirtazipine)

Role of Mental Health ProfessionalsMonitor and Assess signs and symptoms of DM

Educate on DM and blood sugar monitoring

Encourage individuals to take more responsibility for their own health

Role of Mental Health ProfessionalsRemind yourself and your clients that small steps can yield

big results

Listen attentively to your clients and assist them in developing their own healthy living plans

Develop and Implement a healthy living plan: diet, exercise, smoking, alcohol, self-help groups, supportive relationships, medication management

Refer to primary care providers, specialists (podiatry, endocrinology, nutrition, etc.), home health, and support/education groups

Coordinate care between supports systems named above as well as with family and friends

Stages of Change

Pre-contemplation: Not yet acknowledging that there is a problem behavior that needs to be changed

Contemplation: Acknowledging that there is a problem but not yet ready or sure of wanting to make a change

Preparation/Determination: Getting ready to change

Action/Willpower: Changing behavior

Maintenance: Maintaining the behavior change

Initial Questions and ObservationsFor clients without a current diagnosis of DM but are at

increased risk:

Is this person obese?

Is there a family history of DM?

What is the client’s ethnicity?

Is there a family history of physical/sexual abuse?

Initial Questions and ObservationsFor clients without a current diagnosis of DM but are at

increased risk:

Is their diet heavy in fats and salt?

Does the client have high blood pressure?

Does the client have a sedentary lifestyle?

Is the client on medications with known side effect of weight gain?

Diagnosis of Schizophrenia, Bi-Polar Disorder, or Depression?

Initial Questions and Observations For clients with a current diagnosis of DM:

What do you know about your diagnosis?

Do you know the signs and symptoms of low and high blood sugar?

Do you see a PCP about the sugar in your blood?

Describe what you do to help control your diabetes each day?

Initial Questions and Observations For clients with a current diagnosis of DM:

Who tests your blood sugar?

If you test your own blood sugar, do you: Do you have a glucose meter?

Do you have test strips?

Do you keep a record of your blood sugar is and the time you tested it?

Do you understand what you need to do if your blood sugar is high or low?

Common DM Related TestsThree different tests the healthcare provider can use to

determine whether a person is pre-diabetic:

The A1C test

The fasting plasma glucose test (FPG) abnormal blood glucose level indicates impaired fasting glucose (IFG)

Oral glucose tolerance test (OGTT) abnormal blood glucose level indicates impaired glucose tolerance (IGT)

IFG and IGT are both also known as pre-diabetes

What Type I DM signs/symptoms to observe for?

Symptoms of Type I DM:

Unusual thirst

Extreme hunger

Unusual weight loss

Extreme fatigue and irritability

Fruity breath (ketones)

What Type II DM signs/symptoms to observe for?

Symptoms of Type II DM:

Any of the type I symptoms

Frequent infections

Blurred vision

Cuts/bruises that are slow to heal

Tingling/numbness in the hands/feet

Recurring skin, gum, or bladder infections

* Often people with type II DM have no symptoms

High Blood Sugar (Hyperglycemia) Skipping or forgetting insulin or oral glucose-lowering

medicine

Eating too much carbohydrates

Eating too much food and having too may calories

Infection

Illness

Increased stress

Decreased activity or exercising less than usual

Overly strenuous physical activity

Early Signs of HyperglycemiaIncreased thirst/hunger

Headaches

Difficulty concentrating

Blurred vision

Frequent urination

Fatigue (weak, tired feeling)

Weight loss

Prolonged Signs of Hyperglycemia Skin infection

Slow healing cuts or sores

Decreased field of vision

Nerve damage causing painful, cold, or insensitive feet

Loss of hair in lower extremities

Erectile dysfunction

Stomach or intestinal problems such as vomiting, diarrhea, or constipation

Urgent Hyperglycemia Conditions Urgent signs:

Seizures Hallucinations Confusion Disorientation Coma

Two specific types of hyperglycemic conditions:

1. Ketoacidosis: primarily type I DM, dangerously high levels of ketone acids in the blood

2. Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): primarily type II DM, usually brought on by illness or infection

Urgent Hyperglycemia Conditions

Urgent signs: Seizures Hallucinations Confusion, Disorientation, and Coma

Two specific types of hyperglycemic conditions: Ketoacidosis: primarily type I DM, dangerously high levels

of ketone acids in the blood Hyperglycemic Hyperosmolar Nonketotic Syndrome

(HHNS): primarily type II DM, usually brought on by illness or infection

Low Blood Sugar (Hypoglycemia)Blood glucose below normal levels

Can happen suddenly

Usually mild

Can be treated quickly and easily by eating or drinking a small amount of glucose-rich food:

Sugary candy

Banana

Peanut butter

Crackers

Signs of HypoglycemiaHunger

Shakiness

Nervousness

Sweating

Dizziness or light-headedness

Signs of HypoglycemiaCONFUSION and AGITATION/Combativeness

Difficulty speaking

Anxiety

Weakness

If severe/untreated: seizures, coma, and death

Hypoglycemia During SleepSigns include:

Crying out or having nightmares

Finding pajamas or sheets damp from perspiration

Feeling tired, irritable, or confused after waking up

Chronic uncontrolled DM Complications Complications of Diabetes are found in all body

systems: Eyes Peripheral nervous system Blood vessels Heart

EyesPersons with diabetes are at risk for eye diseases that

can lead to blindness

Blurred vision can be a safety issue

Regular check-up are needed at least once a year—check when reviewing care plan

Peripheral Nerve PainDM nerve pain has been described by some patients as

constant or that it comes and goes

Everyday things (bed sheets, socks) may cause pain

Words clients used to describe this pain: Aching Burning Numbness Shooting Pain Stabbing Throbbing Tingling

Blood Vessels: Skin and CirculationDM impairs the ability of the body to heal – feet are especially

affectedEncourage the client to perform skin assessment Inspect between the toes, bottom of the feet, and the heels

for: Broken skin Sores Blisters Areas of increased warmth or redness Changes in calluses

If your client presents with these conditions, please inform your medical staff before infection takes hold

Podiatrist referral/linkage for toe nail cutting/foot care

Kidneys and HeartChanges in blood pressure may indicate kidney damage

Refer to appropriate health care provider for routine lab tests/treatment

Heart attacks/failure are the major cause of death for persons with DM

What can I eat if I have diabetes?Eat lots of vegetables and fruit

Eat non-starchy vegetables such as spinach, carrots, broccoli or green beans with meals

Choose whole grain foods over processed grain products.

Try brown rice with stir-fry or whole wheat spaghetti with pasta sauce

Avoid foods high in fat (e.g. foods fried in oil or fat)

Choose liquid oils for cooking instead of solid fats (high in saturated and trans fats)

What can I eat if I have diabetes?Include dried beans (like kidney or pinto beans) and

lentils

Include fish in your meals 2-3 times a week

Choose lean meats like cuts of beef and pork that end in "loin" such as pork loin and sirloin

Remove the skin from chicken and turkey.

Choose non-fat dairy products such as skim milk, non-fat yogurt and non-fat cheese

If you're trying to lose weight, watch your portion sizes

ExerciseAnything that gets you moving, such as walking,

dancing, or working in the yard

Increases muscle/bone strength, flexibility, and endurance needed for daily activities

Helps the client feel and look better

Lowers blood glucose, blood pressure, and cholesterol

Reduces risk for heart disease and stroke

For optimal weight loss regimen, a combination of physical activity and wise food choices can help reach and maintain target weight

Glucose MetersThings to know about glucose meters:

Meters are vital to keeping track of day-to-day blood glucose levels

They're accurate, but improper use or faulty materials can cause incorrect readings

Many kinds of meters are available

Meters are relatively inexpensive—however test strips are expensive

Glucose MetersExperts testing meters in the lab setting found them accurate

and precise. But meter mistakes most often come from the person doing the blood checks.

For good results you need to do each step correctly.

Other things that can cause a meter to give a poor reading: Dirty meter Meter or strip that's not at room temperature Outdated test strip Meter not calibrated (set up for) the current box of test strips Blood drop that is too small

Client should ask their health care team to check their skills at least once a year

Supports and Referrals Interventions focused on prevention and information/activities:

The internet: local groups, message boards, education, statistics, podcasts, self-assessment of risk factors www.cdc.gov/diabetes American Diabetes Association: www.diabetes.org CDC BMI chart:

http://www.cdc.gov/healthyweight/assessing/bmi/

Referral/Linkage with RN, PCP, Specialty Providers (podiatrist, endocrinologist, ophthalmologist, dentist, nutritionist, etc.), local diabetes groups, Home health

CASE STUDIES

Case Study 1James is a 45 year old African American male with a

diagnosis of schizophrenia. He has stopped taking his medication since he was laid off six months ago. He currently has no insurance and has not applied for SSI or SSDI. He is 5’9” and 196lbs. He noted some weight gain (15 pounds) over the past few months from inactivity.

Recently, at a health fair, he had his blood sugar checked and he was told it was 187. His blood pressure was 140/92. He was told to follow up with a primary health care provider, but he states he isn’t sure where to go because of his lack of health insurance.

Case Study 1What are some of the risk factors James has for

diabetes?

How might a case manager follow-up with the psychiatric health care provider?

What other types of linkages/resources would be helpful for James?

What kind of education could you do with James?

Where would you document this information?

Case Study 2Mary Beth is a 37 year old Caucasian female who has a

diagnosis of schizoaffective disorder. She has been taking Geodon, Depakote, and Prozac. Through her medical health care provider, she is prescribed Glucophage (metformin), an oral medication to control her diabetes.

Her primary healthcare provider has her checking her blood sugar at least once a day. Lately it has been in the low 200s. She states she has been under a lot of stress lately since her son was incarcerated and hasn’t been sticking to her dietary plan. She also notices she has put on a few pounds.

Case Study 2 What are important assessment questions for Mary Beth?

What are some symptoms of high blood sugar that you could look for in Mary Beth?

What are some of the risk factors that predispose Mary Beth for diabetes?

What are some of the medications to watch out for that have a higher risk of leading to weight gain and diabetes?

How might a case manager follow-up with the psychiatric health care provider and primary care provider?

If Mary Beth was having trouble using her blood glucose machine, who should she see to learn how to use it correctly?

Case Study 3 Larry is a 48 year old Chinese American with a psychiatric diagnosis of

paranoid schizophrenia. He was recently diagnosed with end stage renal disease as a complication of his diabetes. Larry’s blood glucose readings ranged between 60 to 300 depending on when it is taken. His registered nurse, Susan, goes to Larry’s apartment to assess his psychiatric and medical condition and to administer his medications everyday.

When Andy, Larry’s case manager visited him, Larry appeared very anxious. He was pacing in his apartment and appeared irritable. Larry has a frown on his face and was cursing under his breath. He began to use profane language and asked if his plane reservations have been made and if his clothes were packed. Larry’s skin appeared sweaty and clammy, he was belligerent, and he slurred his speech more than he usual. After a few minutes of pacing his apartment, he threw his television remote control at his window and yelled at Andy, telling him to “get the f@#k out of my house!!!” Andy was confused as he felt that they had always had a positive working relationship.

Case Study 3What should Andy do at that moment?

What are some possible explanations for Larry’s behavior?

When Andy returns to his agency, what should he communicate to his treatment team?

Whose expertise should he seek to formulate a treatment plan?

What should be the team’s action steps in response to Larry’s outburst?

Questions?

Evaluation. Please take a moment to give me

feedback!

Thanks!!