Improving Care and Promoting Health in Populations

Align approaches to diabetes management with the 'Chronic Care Model'. This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal setting between all team members. (Evd - A)

Tailoring Treatment for Social Context

Assess food insecurity, housing insecurity/homelessness, financial barriers, and social capital/social community support to inform treatment decisions, with referral to appropriate local community resources. (Evd - A)

Provide patients with additional self-management support from lay health coaches, navigators, or community health workers when available. (Evd A)

Comprehensive Diabetic Management Checklist

1. HbA1c Monitoring:
   • Frequency: Check HbA1c at least every 6 months.
   • Medication Adjustment: Base adjustments on HbA1c levels rather than fasting or random glucose, as these are less reliable for ongoing management.
2. Statin Therapy:
   • Recommendation: Prescribe statins (simvastatin 40mg OD or atorvastatin 10mg) for all patients unless contraindicated, particularly for women of childbearing age planning pregnancy.
3. Blood Pressure Management:
   • Targets: Maintain BP below 140/90 mmHg, and lower to <130/80 mmHg in patients with chronic kidney disease (CKD).
4. Retinopathy Screening:
   • Frequency: Perform a retinal examination at least once a year to detect any signs of retinopathy early.
5. Foot Examination:
   • Frequency: Annually check for peripheral neuropathy and circulation issues using a 10g monofilament and vibration sense.
6. Smoking Cessation:
   • Approach: Encourage patients to stop smoking in a supportive manner.
7. Lifestyle Modifications:
   • Weight Control and Exercise: Promote healthy weight and regular physical activity.
8. Lab Investigations:
   • Annual Checks: Monitor U&E, LFT, lipid profile, and urine albumin-creatinine ratio.
9. Patient Education:
   • Topics: Educate patients on dietary advice, monitoring techniques, and the importance of detecting complications early.

Glycemic Control Strategies