Endocrinology TeleECHO Program Case Presentation Form Cover Sheet

Complete ALL ITEMS on this form and email to Dragana Lovre, MD (DLovre@Tulane.edu) Sessions held every other Tuesday at 11:45AM Central Time .

1. Presenter Name and Credentials*:

2. Presenter Cell Phone Number*:

3. Presenter Email*:

4. Clinic/Facility Name and City*:

When do you want to present your case?

* We need your contact information to confirm case receipt

and to notify you if the case needs to be rescheduled.

PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any Tulane University clinician and any patient whose case is being presented in a Project ECHO® setting.

When we receive your case, we will email you with a confidential patient ID number (ECHO ID) that must be utilized when identifying your patient during the session.

We are working hard to change the language around diabetes by adopting person-centered, strengths-based, and empowering words and messages. Please avoid using “diabetic,” “compliant,” “adherent,” or “control,” when

presenting people who have diabetes. Instead, use “person with diabetes,” “diabetes-related,” and “he takes his medications about half the time.” We will all learn and practice this together – thanks for your support!

The information on this form is privileged and confidential. It is intended only for the use of the recipient at the location above. If you have received this in error, any dissemination, distribution or copying of this communication is strictly prohibited.

Diabetes (Adult)

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Endocrinology TeleECHOTM Program— DIABETES (ADULT) CASE PRESENTATION TEMPLATE —

PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any Tulane clinician and any patient whose case is being presented in a Project ECHO setting.

Date: _________________ Presenter Name: ________________________________ Clinic Site: ____________________

ECHO ID: ____________ ☐ New ☐ Follow Up Patient Age: ________ Designated Sex: ☐ Male or ☐ Female

Primary Insurance:______________________________________Secondary Insurance: ______________________________________Race: ☐ American Indian/Alaskan Native, ☐ Asian, ☐ Black/African American, ☐ Native Hawaiian/Pacific Islander,

☐ White/Caucasian, ☐ Multi-racial, ☐ Other: _______________________________________, ☐ Prefer not to say

Ethnicity: ☐ Hispanic/Latinx, ☐ Not Hispanic/Latinx, ☐ Other: ________________________________, ☐ Prefer not to say

Preferred Language: ☐ English, ☐ Spanish, ☐ Navajo, ☐ Other: _________________ Interpreter Required? ☐No ☐Yes

Patient Goals: _______________________________________________________________________________________

Main Question: _____________________________________________________________________________________

___________________________________________________________________________________________________

Diabetes Type: ☐Type 1 Diabetes, ☐Type 2 Diabetes, ☐ Other: ________________ Year of Diagnosis: ________

Years on Insulin: _______Family History of Diabetes? ☐No ☐Yes Family History of Early CAD? ☐No ☐Yes

Symptoms:

PMHx:

☐ Gastroparesis ☐ Nephropathy ☐ Neuropathy ☐ Retinopathy

☐ Coronary Artery Disease ☐ Congestive Heart Failure ☐ Hypertension ☐ Hyperlipidemia

☐ Hypothyroidism ☐ Metabolic Syndrome ☐ Obesity ☐ Osteoarthritis

☐ Peripheral Vascular Disease ☐ Urinary Tract Infection ☐ Obstructive Sleep Apnea ☐ Schizophrenia

☐ Anxiety Disorder ☐ Bipolar Disorder ☐ Depression ☐ Eating Disorder

☐ Other_____________________________________________________________________________________

Recent Hospitalizations: ☐ No ☐ Yes: Describe____________________________________________________

Depression: PHQ9 Done? ☐No ☐Yes (Attach) – Score:___________ Date:____________ Suicidality: ☐ No ☐ Yes

Diagnosis & Treatment History: _______________________________________________________________________

☐ Blurring Vision ☐ Burning/Numbing of Extremities ☐ Depression ☐ Increased Thirst/Urination

☐ Fatigue ☐ Weight Change Since Last Clinic Visit:Increase_______lbs. Decrease_______lbs.

☐ Weakness ☐ Other: __________________

Psychiatric History

Medical History

Medication Allergies: ______________________________________________________________________________

Current Medications/Vitamins/Herbs/Supplements: Please feel free to attach your patient medication list.

Med Name Dosage & Frequency Med Name Dosage & Frequency

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

Insulin Pump: ☐No ☐Yes – Type: _______________________________________ (attach pump readings if available)

Continuous Glucose Monitor: ☐No ☐Yes – Type: ☐ Dexcom, ☐ Libre, ☐ Medtronic ☐ Eversense

Blood Glucose Monitoring: ☐No ☐Yes Average Blood Glucose: _______________ Times Checked/Day: _________

Hypoglycemic episodes/week since last encounter: __________ Self-Reported Data? ☐ No ☐ Yes

_

Marital Status: ☐ Single, ☐ Partnered/Married, ☐ Separated, ☐ Divorced, ☐ Widowed, ☐ Other: ___________________

Literacy Level of Patient or Caregiver: ☐ Limited, ☐ Moderate, ☐ Adequate

Education: ☐ Some High School or Less, ☐ High School/GED, ☐ College or More

Housing: ☐ Secure, ☐ Homeless, ☐ Transient, ☐ Other: _________________________________________________

Household Members: ☐ Parents, ☐ Grandparents, ☐ Spouse/Partner, ☐ Children, ☐ Grandchildren, ☐ Siblings,

☐ Other: ________________________________________________________________________

Primary Source of Income: ☐ Full-time work, ☐ Part-time work, ☐ Pension/Retirement, ☐ SSI, ☐ Social Security,

☐ SSDI, ☐ SNAP, ☐ WIC, ☐ Unemployment, ☐ VA Benefits, ☐ TANF, ☐ No Income,

☐ Other:________________________________________________________

Social Support/Support System: ______________________________________________________________________

Health Beliefs and Cultural Considerations: ____________________________________________________________

Patient Strengths: ___________________________________________________________________________________

Barriers to Treatment: _______________________________________________________________________________

___________________________________________________________________________________________________

Other Comments:_________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Social History

Medications and Technology

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Substance Use History: Does the patient have any history of substance use? ☐No ☐Yes Describe: _____________________________________________________________________________ Does Patient Use Tobacco Products? ☐No ☐Yes – Number per day (1 pack = 20): _____________________

Does Patient Drink Alcohol? ☐No ☐Yes – Number of drinks per week: _______________________________

Nutrition: # of meals per day: _____ Frequency of dining out/week: _____ ☐ Fast Food, ☐ Family Restaurant, ☐

Casino, ☐ Other_____________________________ Please attach a food diary

Does patient count carbs? ☐ No ☐ Yes Use of vitamins and/or herbs: ☐No ☐Yes

Who shops for groceries? ☐ Patient, ☐ Spouse/Partner, ☐ Other Family, ☐ Caregiver, ☐ Other: _____________

Barriers to healthy eating: ☐ Financial, ☐ Social/Family, ☐ Trouble Chewing/Swallowing, ☐ Nausea/Bloating,

☐ Access to Fresh Food, ☐ Prevalence of Fast Food, ☐ Other: ____________________

Physical Activity: Frequency (# of times/week): ____________ Average duration (minutes): ___________

Average intensity: ☐ Low ☐ Moderate ☐ High

Barriers to Exercise: ☐ Time, ☐ Lack of Motivation, ☐ Lack of Resources, ☐ Lack of Self-Confidence,

☐ Inconvenience, ☐ Injury or Fear of Injury, ☐ Lack of Support, ☐ Other:_________________________________

What is your team’s plan for this patient?

___________________________________________________________________________________________________

V

Date: ________________ Systolic BP: _____________ Diastolic BP: ____________ Pulse: _________________

Height: ________________ Weight: ________________ ☐lbs. ☐ kgs. BMI: __________________

Microvascular Screening Results

Dilated Eye Exam/Retinal Scan: Date: ____________ ☐ Normal, ☐ Abnormal - ☐ Mild NPDR, ☐ Moderate NPDR,

☐ Severe NPDR, ☐ PDR

Comprehensive Foot Exam: Date: ______________ ☐ Normal ☐ Abnormal - ☐ Diminished Sensation, ☐Ulcer

☐ Diminished Pulses, ☐ Wound, ☐ Other: ________________

Urine Albumin to Creatinine Ratio: Date: _________ ☐ Normal ☐ Abnormal – UACR: _______________

Sexual Dysfunction Screening: Date: _____________ ☐ Normal ☐ Abnormal__________________________

Current Labs: Date: ________________ HbA1C: Current _______, Previous________ ________ Total Chol: __________ Triglycerides:_______

HDL: _______________ LDL: ___________________ ALT: _______________ AST: ______________

BUN: _______________ Creatinine: _____________ Glucose: ____________ GFR: ______________

TSH: _______________ Potassium: _____________ Proteinuria: ____________ (☐ Dipstick, ☐ Lab)

Other Relevant Labs: _________________________________________________________________________

Other Comments:

Vitals, Screenings, and Labs

Lifestyle

Diabetes (Adult)

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