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«INDIAN HEALTH DIABETES BEST PRACTICE Eye Care Revised April 2011 Note! Please review the Best Practice Addendum, which provides the most current ...»

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INDIAN HEALTH DIABETES

BEST PRACTICE

Eye Care

Revised April 2011

Note! Please review the Best Practice Addendum,

which provides the most current information on the Required

Key Measures along with examples of ways to obtain the

measures. The Best Practice Addendum can be found here:

http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/

BestPractices/BP_2011_Table_RKM_508c.pdf Indian Health Service Division of Diabetes Treatment and Prevention 5300 Homestead Road NE Albuquerque, New Mexico 87110 http://www.ihs.gov/MedicalPrograms/Diabetes/ Table of Contents Instructions for Using This Best Practice

Summary of Key Recommendations and Key Measures

PART 1 Essential Elements of Implementing This Best Practice

Purpose

Target Population

Definition of Diabetes Eye Care

Goals of This Best Practice

Key Recommendations

Planning for Your Program and Evaluation

Key Action Steps

Key Measures

PART 2 Key Recommendations

Note! Part 2 provides important detail on the “why?” and “how?” of implementation of each Key Recommendation

PART 3 Appendices, Tools, and Resources

PART 4 References

Indian Health Diabetes Best Practice Eye Care 2 Instructions for Using This Best Practice The Best Practices are organized into topics on how to plan for and successfully implement a Best Practice in your community.

• Part 1 provides background information on planning for your program and evaluation, Key Recommendations, and Key Measures.

• Part 2 provides details on implementation of the Key Recommendations.

• Part 3 includes appendices, tools, and resources.

• Part 4 provides a list of references.

As you prepare to select, implement, and evaluate a Best Practice, consider these planning

guidelines:

• Meet with your diabetes team to discuss which Best Practice(s) is best suited for your situation and resources.

• Use data from your Diabetes Care Outcomes and Audit and/or from a community needs assessment to guide your selection of the Best Practice(s).

• Determine your program goal(s) as a team. For example, your team may decide to work toward increasing the number of people who receive eye exams.

• Print out at least Part 1 of the Best Practice(s) your team feels is most appropriate to implement.

• Work with your diabetes team to review and discuss the Best Practice(s). You may choose to read it together as a team.

• Choose at least one Best Practice after carefully considering your goals and resources (funding, staff, and time).

• Review the entire Best Practice(s) you have selected with your diabetes team.

 Confirm that you have selected a Best Practice(s) appropriate for your community needs and resources and that you are confident that your team can successfully implement, evaluate (measure), and document progress and outcomes.

 Target the population your team wants to improve outcomes for with the Best Practice(s). Remember, you probably do not have resources to do everything for everyone.

 Carefully consider the Key Recommendations. The recommendations are based on evidence and have been proven to be effective. You may already be doing some of the recommendations and can easily fit these into your plan, or you may want to consider some new recommendations to enhance and strengthen your program.

Identify those your team can implement.

 Carefully review the Key Measures. Choose those that best fit with your goals and the Key Recommendations you have chosen to implement.

 If one Best Practice does not fit, then review another Best Practice until you find one that fits.

Throughout the document you will find links that draw your attention to important items within

the Best Practice pdf. Here is a list of the items:

• Action! Indicates a link. Please use the link to access more detailed descriptions.

• Note! Indicates an important item. Pay special attention to this important item.

Indian Health Diabetes Best Practice Eye Care 3 Summary of Key Recommendations and Key Measures These are evidence-based actions that will lead to improved outcomes in the community. Action! See Part 2 for details on the implementation of each Key Recommendation.

1. Provide a diabetic retinopathy (DR) education component in all diabetes education programs for patients and family.

2. Adhere to the evidence-based accepted standards of care for DR surveillance and use a

qualifying examination for DR surveillance:

• Dilated eye examination by an optometrist or ophthalmologist

• Qualifying photographic retinal examination  Dilated seven standard field stereoscopic photographs (Early Treatment Diabetic Retinopathy Study (ETDRS) photos)  Other photographic method formally validated to ETDRS

3. Recognize early when to refer patient for consideration of treatment.

4. Monitor risk factors and treatments.

5. Provide ophthalmology referral for all cases determined to be at risk for vision loss and possible candidates for treatment and provide visual rehabilitation for patients with vision loss.





These are specific measures that can be used to document changes in outcomes related to implementing the Best Practice.

Note! All SDPI grant programs that choose this Best Practice must report as required in the terms and conditions attached to the notice of award on the indicated Measures.

Programs may report on other measures as well.

* The following measures are of primary importance:

1. *Percent of diabetes patients with a documented qualifying eye exam in the past twelve months.

2. * Percentage of diabetes patients with abnormal retinal screening exam who received appropriate specialty follow up in the past twelve months.

–  –  –

Indian Health Diabetes Best Practice Eye Care 5 Purpose This Best Practice describes guidelines for programs that seek to improve individual’s diabetic eye health status and to enhance the delivery of effective diabetic eye care.

Target Population The target population to be covered by this Best Practice is persons with type 1 or type 2 diabetes.

Action! See Part 3 – Appendix A. for the importance of eye care.

Intended Users of this Best Practice The intended users of this Best Practice are all clinical providers serving all persons with type 1 or 2 diabetes, regardless of the patient’s age or duration of diabetes, or presence/absence of comorbidities.

Action! See Part 3 – Appendix A. Supplemental Information for discussion of the benefits and risks of implementing this Best Practice.

Definition of Diabetes Eye Care People with diabetes mellitus (DM) are at lifelong risk for special problems with their eyes and vision. The complications associated with diabetes can affect visual function and virtually every component of the visual system, from the ocular adnexa and precorneal tear layer, throughout every structure in the eye, and finally to the occipital cortex in the brain. These changes can cause several ocular disorders such as retinopathy, cataracts, and glaucoma that may lead to vision loss or blindness, Because effective treatments for these disorders exist, eye care is an essential element of a diabetes program.

Goals of This Best Practice

• Improve diabetic eye care and services for people with diabetes to prevent diabetic retinopathy.

• Decrease vision loss due to diabetic retinopathy.

–  –  –

These are evidence-based actions that will lead to improved outcomes in the community.

1. Provide a diabetic retinopathy (DR) education component in all diabetes education programs for patients and family.

2. Adhere to the evidence-based accepted standards of care for DR surveillance and use a

qualifying examination for DR surveillance:

• Dilated eye examination by an optometrist or ophthalmologist

• Qualifying photographic retinal examination  Dilated seven standard field stereoscopic photographs (Early Treatment Diabetic Retinopathy Study (ETDRS) photos)  Other photographic method formally validated to ETDRS

3. Recognize early when to refer patient for consideration of treatment.

4. Monitor risk factors and treatments.

5. Provide ophthalmology referral for all cases determined to be at risk for vision loss and possible candidates for treatment and provide visual rehabilitation for patients with vision loss.

Action! See Part 2 for details on the implementation of each key recommendation.

–  –  –

1. Identify your program’s goal(s). There are many program goals consistent with the Key Recommendations of this practice. Choose program goals that fit with the Key

Recommendations and your resources. Examples of program goals include:

• Increase the number of people who receive annual eye exams.

• Increase the number of people needing retinal treatment who receive it.

2. Define program objectives that will be met to reach the program goal(s) in the SMART format (specific, measurable, action-oriented, realistic, and time-bound).

Examples of SMART objectives for this Best Practice:

• Increase the number of people with diabetes with documented eye exams in the past twelve months from 70% to 90% by the end of the current fiscal year.

• By the end of the current fiscal year, we will increase the number of people with diabetes who were identified as needing retinal treatment who have documented treatment by 10%.

3. Use Key Measures. The following Key Measures can be used to monitor progress and the effectiveness of implementing this Best Practice. Results of measures will indicate the degree of success in implementing the Key Recommendations and meeting program goals.

Measures of progress need to occur before the intervention (baseline) and at designated times thereafter. Measurement needs to be frequent enough to provide meaningful information for planning and evaluation.

Key Measures These are specific measures that can be used to document changes in outcomes related to implementing the Best Practice.

Note! All SDPI grant programs that choose this Best Practice must report as required in the terms and conditions attached to the notice of award on the indicated Measures. Programs may report on other measures as well.

*The following measures are of primary importance:

1. *Percent of diabetes patients with a documented qualifying eye exam in the past twelve months.

2. *Percentage of diabetes patients with abnormal retinal screening exam who received appropriate specialty follow up in the past twelve months.

–  –  –

5. Use creative ways to display data and measure outcomes, such as graphs or charts.

This helps the team understand the data and know whether there are improvements.

6. Think about what the data are telling you. What changes are you seeing? Are they improvements? Use data for planning next steps Action! Link to the following resources to help your program improve.

See Part 3 – Appendix B. Key Measures Example to assist you with identifying ways to choose Key Measures that incorporate your community data.

See Part 3 – Appendix C. Improving Eye Care Programs Example to assist you with applying Key Recommendations and Key Measures to a program plan.

.

Action! See online training and a workbook to get more ideas about setting goals and

objectives and developing a program plan. Available from:

http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Training/WebBased/Basics/Creating/ Workbook.pdf (pp. 23–28).

Team Notes:

–  –  –

Indian Health Diabetes Best Practice Eye Care 10 Key Recommendation 1. Provide a diabetes retinopathy (DR) education component in all diabetes education programs for patients and family.

Why?

Control of comorbidities can substantially reduce the onset and progression of diabetic retinopathy (DR), and timely diagnosis and treatment of high risk DR can nearly eliminate blindness due to DR. Because half of American Indian/Alaska Native people fail to achieve DR surveillance standard of care, even in clinical settings wherein the opportunity for this care is immediately available, this message is not being effectively delivered. Eye complications are frequently asymptomatic and go unrecognized by the patient (Giusti, 2001; Taylor et al., 2004), delaying detection and treatment of high risk DR when treatment is most effective. Patient awareness of their role and opportunities in management of their disease can increase compliance with standards of care and reduce vision loss due to diabetes.

How to Implement the Key Recommendation A. Offer annual diabetic eye care/DR education to all patients with diabetes and reinforce this education during follow-up visits.

B. Use pre-printed material such as brochures and structured manuals during initial and follow-up visits (NEHEP, 2011).

C. Use the patient’s current retinal images as an educational tool and clinical demonstration aid following image acquisition. This education should occur at the time of image acquisition during a conventional eye or physical examination or telemedicine encounter, and should be repeated annually.

D. Educate patients and family members about eye guidelines and reinforce the education

during visits. The goal and content of the education should emphasize:

1. The need to maintain blood glucose, blood pressure, and lipid levels as close to normal as possible,

2. the importance of an annual dilated eye exam (or qualifying photographic retinal surveillance) by an optometrist or ophthalmologist,

3. the importance of not smoking,

4. that DR can be totally asymptomatic even at advanced stages, and



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