What is an example of a comprehensive care plan for a patient with diabetes?

Comprehensive Care Plan for a Patient with Diabetes

A comprehensive diabetes care plan should include team-based management with specific glycemic targets, structured lifestyle interventions, appropriate pharmacologic therapy, cardiovascular risk reduction, complication screening protocols, and diabetes self-management education, all coordinated through the Chronic Care Model framework. 1

Team-Based Care Structure

• Assemble a multidisciplinary team including primary care physicians, endocrinologists, diabetes care and education specialists, registered dietitian nutritionists, pharmacists, podiatrists, ophthalmologists, and mental health professionals 1, 2
• Align care delivery with the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient 1, 2
• Establish the patient as an active participant in their care, with treatment decisions made collaboratively based on patient preferences, values, and goals 1

Initial Comprehensive Medical Evaluation

Medical History Components:

• Document diabetes type, duration, previous A1C records, and current glycemic control patterns 1, 2
• Review all current diabetes medications including doses, adherence patterns, and any side effects or intolerances 1
• Assess frequency and severity of acute complications: hypoglycemic episodes (including time of day, precipitating factors, symptoms, and treatment response) and any history of diabetic ketoacidosis 1, 2
• Document eating patterns, nutritional status, weight history, and previous nutrition education 1
• Record exercise history including type, frequency, duration, and barriers to physical activity 1, 2
• Screen for symptoms of chronic complications: visual changes, kidney disease symptoms, neuropathic pain or numbness, gastrointestinal symptoms, genitourinary dysfunction including sexual dysfunction, and cardiovascular symptoms 1, 2
• Identify current infections, particularly skin, foot, dental, and genitourinary infections 1

Physical Examination:

• Measure height, weight, BMI, and waist circumference 2, 3
• Obtain blood pressure in both arms 2
• Perform comprehensive foot examination including inspection for deformities, skin integrity, pulses, and monofilament testing for neuropathy 2, 3
• Conduct fundoscopic examination or arrange ophthalmology referral 2

Laboratory Assessment:

• Obtain A1C (if not measured in prior 3 months) 1, 2, 3
• Measure fasting lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides) 2, 3
• Assess kidney function with serum creatinine and estimated GFR 2, 3
• Obtain urine albumin-to-creatinine ratio 2, 3
• Check liver function tests if considering certain medications 2
• Screen for thyroid dysfunction in type 1 diabetes 2
• Consider screening for celiac disease in type 1 diabetes 2

Glycemic Management Plan

Set Specific A1C Targets:

• Establish individualized A1C goals based on age, duration of diabetes, presence of complications, comorbidities, hypoglycemia risk, and life expectancy 1, 2
• For most non-pregnant adults, target A1C <7% 2
• Consider more stringent goals (<6.5%) for selected patients if achievable without significant hypoglycemia 2
• Consider less stringent goals (<8%) for patients with limited life expectancy, advanced complications, or extensive comorbidities 2

Blood Glucose Monitoring:

• Prescribe self-monitoring of blood glucose with frequency appropriate to medication regimen 3
• For patients on multiple daily insulin injections or insulin pump therapy, recommend testing before meals, occasionally postprandially, at bedtime, prior to exercise, when hypoglycemia is suspected, after treating hypoglycemia, and before critical tasks 2
• Schedule A1C testing every 3 months if not at goal or therapy has changed; every 6 months if at stable goal 2, 3

Pharmacologic Therapy

For Type 1 Diabetes:

• Initiate multiple daily insulin injections (basal-bolus regimen) or continuous subcutaneous insulin infusion 2
• Use rapid-acting insulin analogues for prandial coverage to reduce hypoglycemia risk 2
• Prescribe basal insulin (long-acting analogue preferred) for background insulin needs 2
• Educate on carbohydrate counting and insulin-to-carbohydrate ratios for prandial dose adjustment 2
• Teach correction factor calculations for hyperglycemia management 2

For Type 2 Diabetes:

• Start metformin at diagnosis alongside lifestyle modifications if eGFR >30 mL/min/1.73 m² 2, 3
• Begin with 500 mg once or twice daily with meals, titrating up by 500 mg weekly to maximum tolerated dose (typically 2000 mg daily) to minimize gastrointestinal side effects 2
• For patients with marked hyperglycemia (glucose ≥250 mg/dL or A1C ≥8.5%) with symptoms, initiate basal insulin immediately while starting metformin 3
• If A1C remains above target after 3 months on maximum tolerated metformin dose, add a second agent selected based on patient-specific factors 2, 3
• Consider GLP-1 receptor agonists or SGLT2 inhibitors for patients with established cardiovascular disease or high cardiovascular risk 2
• Add basal insulin if dual therapy fails to achieve glycemic targets 2

Lifestyle Management Program

Medical Nutrition Therapy:

• Refer to registered dietitian nutritionist for individualized meal planning 2, 3
• Implement eating pattern based on patient preferences: Mediterranean-style, DASH, plant-based, lower-fat, or lower-carbohydrate approaches are all acceptable 2
• For weight loss, prescribe 500-750 kcal/day energy deficit 2, 3
• Reduce intake of saturated fat (<7% of total calories), trans fat, and cholesterol (<200 mg/day) 2
• Increase intake of omega-3 fatty acids, viscous fiber (10-25 g/day), and plant stanols/sterols (2 g/day) 2
• Provide education on carbohydrate counting for patients on insulin therapy 2

Physical Activity Prescription:

• Prescribe at least 150 minutes per week of moderate-intensity aerobic activity (50-70% maximum heart rate) spread over at least 3 days with no more than 2 consecutive days without activity 2
• Add resistance training at least 2 times per week on non-consecutive days 2
• Recommend reducing sedentary time by breaking up prolonged sitting every 30 minutes 2
• Screen for contraindications before initiating exercise program, particularly in patients with proliferative retinopathy, severe neuropathy, or cardiovascular disease 2

Weight Management:

• For overweight/obese patients (BMI ≥25 kg/m²), prescribe high-intensity behavioral therapy designed to achieve ≥5% weight loss 2, 3
• Implement structured weight loss programs with frequent contact (≥16 sessions in 6 months) 3
• Consider pharmacologic agents for weight loss if lifestyle interventions are insufficient 3
• Discuss metabolic surgery for patients with BMI ≥40 kg/m² (or ≥37.5 kg/m² in Asian Americans) or BMI ≥35 kg/m² with inadequate glycemic control despite optimal medical therapy 2

Cardiovascular Risk Reduction

Blood Pressure Management:

• Target blood pressure <140/90 mmHg for most patients with diabetes 2
• Consider target <130/80 mmHg for patients at high cardiovascular risk if achievable without undue treatment burden 2
• Initiate lifestyle modifications: weight loss if overweight, DASH diet, sodium restriction (<2300 mg/day), moderation of alcohol intake, and increased physical activity 2
• Start pharmacologic therapy with ACE inhibitor or ARB (but not both simultaneously) for patients with blood pressure ≥140/90 mmHg 2
• Add additional antihypertensive agents as needed to achieve target 2

Lipid Management:

• Initiate moderate-intensity statin therapy for all patients aged 40-75 years with diabetes 2
• Use high-intensity statin for patients with established atherosclerotic cardiovascular disease 2
• For patients <40 years with additional cardiovascular risk factors, consider statin therapy 2
• Recheck lipid panel 4-12 weeks after statin initiation and annually thereafter 2
• Add ezetimibe if LDL-C remains ≥70 mg/dL on maximally tolerated statin in patients with atherosclerotic cardiovascular disease 2

Antiplatelet Therapy:

• Prescribe aspirin 75-162 mg daily for secondary prevention in patients with diabetes and history of atherosclerotic cardiovascular disease 2
• Consider aspirin for primary prevention in patients at increased cardiovascular risk after comprehensive discussion of benefits versus bleeding risk 2

Smoking Cessation:

• Assess tobacco use at every visit 2
• Provide counseling and pharmacologic therapy (varenicline, bupropion, or nicotine replacement) for all tobacco users 2

Complication Screening and Prevention

Retinopathy Screening:

• Arrange comprehensive dilated eye examination by ophthalmologist or optometrist at diagnosis for type 2 diabetes 2, 3
• For type 1 diabetes, perform initial examination within 5 years of diagnosis 2
• Repeat annually if no retinopathy; every 1-2 years if mild nonproliferative retinopathy 2
• Refer immediately to ophthalmologist if any vision-threatening retinopathy detected 2

Nephropathy Screening:

• Measure urine albumin-to-creatinine ratio and estimated GFR annually starting at diagnosis for type 2 diabetes 2, 3
• For type 1 diabetes, begin screening 5 years after diagnosis 2
• If albuminuria present, initiate ACE inhibitor or ARB regardless of blood pressure 2
• Monitor kidney function and adjust medications as eGFR declines 2

Neuropathy Assessment:

• Perform comprehensive foot examination annually including 10-g monofilament testing, vibration sensation with 128-Hz tuning fork, pinprick sensation, ankle reflexes, and visual inspection 2, 3
• Screen for symptoms of distal symmetric polyneuropathy (numbness, tingling, pain) and autonomic neuropathy (gastroparesis, erectile dysfunction, neurogenic bladder, orthostatic hypotension) 2
• Refer to podiatrist for patients with foot deformities, prior ulceration, or loss of protective sensation 2
• Provide education on daily foot self-examination and proper footwear 2

Cardiovascular Disease Screening:

• Obtain baseline electrocardiogram in adults with diabetes 2
• Consider stress testing in patients with typical or atypical cardiac symptoms, abnormal resting ECG, peripheral arterial disease, carotid disease, or sedentary lifestyle planning to start vigorous exercise 2

Diabetes Self-Management Education and Support

Initial Education Program:

• Refer all patients to diabetes self-management education program at diagnosis 2, 3
• Ensure education covers: pathophysiology of diabetes, treatment options, glucose monitoring techniques, hypoglycemia recognition and treatment, hyperglycemia management, medication administration, nutrition principles, physical activity recommendations, complication prevention, psychosocial adjustment, and problem-solving skills 2
• Use patient-centered communication that incorporates patient preferences, assesses health literacy and numeracy, and addresses cultural barriers 1

Ongoing Support:

• Provide diabetes self-management support at critical times: diagnosis, annually, when not meeting treatment targets, when complications develop, and during transitions in care 2
• Assess self-efficacy and barriers to self-management at each visit 1, 2
• Use nonjudgmental language that normalizes periodic lapses in self-management 1

Immunizations

• Administer annual influenza vaccine to all patients ≥6 months of age 1, 2
• Provide pneumococcal polysaccharide vaccine (PPSV23) to adults with diabetes aged 19-64 years 2
• Give pneumococcal conjugate vaccine (PCV13 or PCV15) followed by PPSV23 to adults ≥65 years 2
• Ensure hepatitis B vaccination series for unvaccinated adults with diabetes aged 19-59 years 2
• Provide all other age-appropriate vaccinations per CDC guidelines 1, 2

Follow-Up Care Schedule

Routine Visits:

• Schedule visits every 3 months for patients not at glycemic goal or with recent therapy changes 3
• See patients every 6 months if at stable glycemic goal 3
• At each visit: review glucose monitoring data, assess medication adherence and side effects, check blood pressure and weight, examine feet, review self-management behaviors, assess psychosocial status, and adjust treatment plan as needed 1, 3

Annual Assessments:

• Comprehensive foot examination 2, 3
• Dilated eye examination 2, 3
• Urine albumin-to-creatinine ratio and eGFR 2, 3
• Fasting lipid profile 2, 3
• Review of all medications and immunization status 2, 3

Special Considerations

Hypoglycemia Management:

• Educate patients to treat blood glucose <70 mg/dL with 15-20 grams of rapid-acting carbohydrate (glucose tablets, juice, regular soda) 2
• Recheck glucose in 15 minutes and repeat treatment if still <70 mg/dL 2
• Prescribe glucagon emergency kit for patients on insulin or insulin secretagogues and train family members on administration 2
• Identify situations increasing hypoglycemia risk: fasting for procedures, during or after exercise, during sleep, and after alcohol consumption 1, 2

Psychosocial Assessment:

• Screen for diabetes distress, depression, anxiety, disordered eating, and cognitive impairment at initial visit and periodically thereafter 1
• Refer to mental health professional when indicated 1
• Assess social determinants of health including food insecurity, housing stability, and financial barriers to care 1, 3

Common Pitfalls to Avoid

• Clinical inertia: Failing to intensify therapy when glycemic targets are not met leads to prolonged hyperglycemia and increased complication risk; review and modify treatment plan at each visit if A1C remains above goal 1
• Inadequate patient education: Simply providing information without assessing understanding and addressing barriers results in poor self-management; use teach-back methods to confirm comprehension 2
• Neglecting cardiovascular risk factors: Focusing solely on glucose control while ignoring blood pressure, lipids, and smoking cessation misses opportunity for major mortality reduction 1, 2
• Overlooking foot care: Failure to perform annual comprehensive foot examinations and provide preventive education increases amputation risk 1, 2
• Medication errors during transitions: Hospital discharge and transitions between providers are high-risk periods; perform medication reconciliation and ensure clear communication 1
• Ignoring patient preferences: Imposing treatment plans without collaborative decision-making reduces adherence; always incorporate patient values and goals 1