CALIFORNIA DIABETES&

PREGNANCY PROGRAM

“CDAPP SWEET SUCCESS”

APPLICATIONto BECOME A CDAPP

SWEET SUCCESS AFFILIATE

2015Overview: The California Diabetes and Pregnancy

Program (CDAPP)Sweet Success

History:CDAPP Sweet Success began as a pilot project in San Francisco in 1982, funded by the March of Dimes. Based on the success of that pilot project, the Inland Counties in Southern California became the first CDAPP regional program funded by federal Title V Block Grant through the California Maternal, Child and Adolescent Health (MCAH) Division.

CDAPP Sweet Success regional programs were originally established based on the regional perinatal health systems model. The regional program consisted of a multidisciplinary team that ideally included a diabetes nurse educator, a registered dietitian, and a behavior medicine specialist who worked in conjunction with a regional medical director. Due to budget shortfall, funding for ten regional CDAPP Sweet Success programs ended in June 2012. A new statewide CDAPP Sweet Success Resource and Training Center was established starting July 1, 2012 to support and train our CDAPP Sweet Success Affiliates.

The CDAPP Sweet Success Resource and Training Center develops and maintains web-based training and disseminates valuable diabetes resources.

CDAPP Sweet Success Affiliates provide direct health services that promote optimal management of diabetes, before, during, and after pregnancy. Affiliates are encouraged to: Use the CDAPP Sweet Success Guidelines for Care. Utilize interdisciplinary health care teams to provide preventive and health

promoting strategies that are culturally appropriate and research-based. Collect and analyze clinical data for validation of services to patients and for

quality improvement (QI) activities.

CDAPP Sweet SuccessAffiliation Application BackgroundMission:The mission of the California Diabetes and Pregnancy Program (CDAPP) Sweet Success is to promote best practices of care for pregnant women who have diabetes. CDAPP Sweet Success strives to optimize maternal and neonatal birth outcomes, and reduce the complications of diabetes among women with preexisting diabetes and slow or prevent the development of ongoing diabetes among women with gestational diabetes.

Goals:CDAPP Sweet Success goals are: To improve pregnancy outcomes for high-risk pregnant women who have

preexisting diabetes or who develop gestational diabetes during pregnancy, To reduce fetal deaths and neonatal and maternal complications due to

diabetes.

We accomplish these goals through the CDAPP Sweet Success Resource and Training Center which:

Develops updates and disseminates CDAPP Sweet Success Guidelines for Care that provides guidelines to care for women with diabetes before, during and following pregnancy.

Recruits, educates, and provides technical assistance to CDAPP Sweet Success Affiliates who provide clinical care to pregnant women with diabetes. Clinical care provided by CDAPP Sweet Success Affiliates includes comprehensive individualized services such as outpatient health education, nutrition, psychosocial and medical services.

Develops ethnic/language specific professional and patient education materials, and resources.

Promotes awareness of the importance of preconception care for women with pre-existing diabetes.

Collaborates with the Comprehensive Perinatal Services Program, (CPSP), the California Diabetes Program (CDP) and other appropriate networks.

These goals are consistent with those of the California Department of Public Health, Maternal, Child and Adolescent Health Division funded through Federal Title V Block Grant.

CDAPP Sweet Success AffiliateRole of the Team

CDAPP Sweet Success Affiliates use a multidisciplinary team. The team is comprised of various health care professionals, depending on the health care setting, and can include physicians, nurse educators, nurse practitioners, certified nurse midwives, health educators, physician assistants, behavioral medicine specialists (social workers, marriage/family therapists, and clinical psychologists), registered dietitians, and medical assistants. The roles of these team members may overlap in some cases, but all team members work closely with the woman throughout her pregnancy. Team members need understanding of the physiology and management of pregnancies complicated by diabetes as well as experience in educating women about diabetes related issues.

MCAH provides: Title V federal funding for CDAPP Sweet Success Resource and Training

Center Program Consultants for CDAPP Sweet Success who provide direction

and oversight in communicating the MCH Title V goals and objectives to the CDAPP Sweet Success Resource and Training Center.

CDAPP Sweet Success Resource and Training Center provides: The “CDAPP Sweet Success Guidelines for Care”, The CDAPP Sweet Success Resource and Training Center Website. The CDAPP Sweet Success materials and brochures to affiliates and

providers in electronic formats. Web-based educational trainings for existing and new CDAPP Sweet

Success Affiliates Assistance to affiliates in order to maintain their Memorandum of

Understanding (MOU) and inclusion in the online CDAPP Sweet Success Affiliate Directory.

Collection of CDAPP Sweet Success Affiliate On-line Annual Surveys including number of clients served.

Annual Certificates of Affiliate Status that can be displayed verifying the site has met requirements.

An Annual Report to the MCAH Division.

CDAPP Sweet Success Affiliates provide: A health care team knowledgeable about the CDAPP Sweet Success

Guidelines for Care and utilizes these guidelines in their current practice. Patient management based upon participation in CDAPP Sweet Success

training programs. Comprehensive clinical preconception and pregnancy care for women

with diabetes Clinical competency by ongoing participation in yearly educational

programs.

Data collection about the care they provide to clients in order to self-monitor and evaluate their clinical practices.

Feedback and sharing of their goals and plans with the CDAPP Sweet Success Resource and Training Center staff through annual on-line site survey.

Promotion of diabetes awareness in the community and participation in diabetes educational programs

Cost Effectiveness:Studies have shown that $3.00 to $5.00 is saved for every $1.00 spent on diabetes and pregnancy care. (Kitzmiller JL. Pre-conception care of diabetes, congenital malformations, and spontaneous abortions. Diabetes Care. 1996;19(5):514-541.)

Resources:CDAPP Sweet Success Web siteshttp://www.cdph.ca.gov/programs/cdapp/Pages/default.aspx

CDAPP Sweet Success Resource and Training Center website:http://www.cdappsweetsuccess.org/

CDAPP Sweet SuccessAFFILIATION APPLICATION

PROCESS Complete a CDAPP Sweet Success Affiliation Application and submit it to

the CDAPP Sweet Success Resource and Training Center.

Following application review and approval by the CDAPP Sweet Success Resource and Training Center, a Memorandum of Understanding (MOU) that describes what is required of an affiliate and the support that is provided by CDAPP Sweet Success Resource and Training staff will be sent to you. The MOU is to be signed by both a representative of your program and the CDAPP Sweet Success Resource and Training Center.

All affiliate staff, and all new staff as they become part of your team, who have not already attended CDAPP Sweet Success required training will need to do so within one year of affiliation.

After training is completed, your site will be added to the CDAPP Sweet Success Resource and Training Center and to the State CDAPP Sweet Success web sites as part of the CDAPP Sweet Success Affiliate Directory.

Follow-up consultation will be provided by CDAPP Sweet Success Resource and Training Center staff on an as needed basis.

An On-Line Annual Survey will be conducted by the CDAPP Sweet Success Resource and Training Center to assess and provide assistance to your program. (Refer to the CDAPP Sweet Success On-Line Annual Survey).

Memorandum of Understanding (MOU) – the MOU details the agency’s agreement to:

Follow CDAPP Sweet Success Guidelines for Care Ensure all affiliate staff are trained in the care of women with diabetes Participate in on-line annual site survey by CDAPP Sweet Success Resource

and Training Center staff including data regarding number of clients served.

CDAPP Sweet SuccessAFFILIATION APPLICATION*

Date Click here to enter a date.Agency Name FORMTEXT      Street Address FORMTEXT      Telephone/Fax FORMTEXT      Email Address FORMTEXT      Type of Agency(double click to check box)

MD Office Medical Center Clinic Community Clinic Diabetes Center Other:      

Name/Credentials Email Phone LanguagesSpoken

FTEin SS

Hrs/Days in SS

Medical Director(Must be a practicing physician who sees diabetic patients)CDAPP Sweet Success Program Coordinator/ Contact(must be licensed)Dietitian(s)

Nurse Educator(s)

Behavioral Medicine Specialist(s)

Obstetrician(s)

EndocrinologistOthers

* Please indicate with an * who will be the designated person to initiate and finalize data collection. Also, to check any box in this fill-in document, just scroll over that box with your mouse and double click. A window should pop up allowing you to check that given box.

CDAPP Sweet SuccessAFFILIATION APPLICATION

To check any box in this fill-in document, just scroll over that box with your mouse and double click. A window should pop up allowing you to check that

given box.1. Services you plan to provide. Check the services you will provide: Preconception counseling for: Type 1 diabetes Type 2 diabetes Antepartum Type 1 diabetes Type 2 diabetes Intrapartum Type 1 diabetes Type 2 diabetes GDM Postpartum medical management of:

Type 1 diabetes Type 2 diabetes GDM Medical nutrition therapy for complex situations (e.g. multiples, hyperemesis) Diabetes self-management education (includes meal planning, physical activity

planning, how to take medication, coping support, problem-solving strategies, how to reduce risks, self-monitoring of blood glucose (SMBG)

Continuous subcutaneous insulin therapy Other Services: Click here to enter text.

2. Volume of patients you expectExpected number of new patients per month with GDM      Expected number of new patients per month with Type 1 diabetes      Expected number of new patients per month with Type 2 diabetes      

3. Program accepts Medi-Cal? Yes No If yes, are you a CPSP provider? Yes No

4. Site is part of an ADA recognized diabetes program? Yes No

5. Will you have a budget for purchasing education materials? Yes No

All of our educational materials are made free to download from our website at no cost to you. The cost you would incur is printing it out on your own (i.e. ink, paper and time) or utilizing an outside printing company.

6. Identify referral sites/resources for clients who need care which you are unable to provide with on-site staff. This may include the following: (Indicate names and location of such resources.) Perinatologist       Endocrinologist       Psychosocial practitioners       Public health resources      

7. Identify the hospital(s) in which your clients will deliver:      

DETERMINING FTE NEEDS FOR THE SWEET SUCCESS

PROGRAMThe full-time equivalent (FTE) calculations for staff in a CDAPP Sweet Success Affiliate include those needed for patient education and services.

A CDAPP Sweet Success Affiliate needs designated staff to address and provide services including nursing (RN), dietitian (RD), and behavioral medicine specialist (BMS). The mix of patients usually includes some that are there for the initial visit and some that are there for follow-up visits. Some patients will only require diet and activity management, while others will need oral diabetic agents or insulin. These factors including the total number of patients seen will affect the FTE calculation.

Generally, an initial educational visit will be about 2 hours comprised of about 45 -60 minutes for the RN, about 30-45 minutes for the RD, and about 30 minutes for the BMS.

For a new patient requiring insulin teaching another 60 minutes may be needed. Follow-up visits at 1-2 week intervals usually are about 15-30 minutes.

To determine FTE needed, calculate: # New patients per week x 2 hours. # New patients on insulin per week x 1 hour. # F/U patients per week x 30minutes. # Total hours per week /3 staff (RN, RD, BMS) = # hours each or about # FTE each.

# FTE x 3= FTE total time per week.

For example:In one year, the number of Sweet Success patients seen by a CDAPP Sweet Success Affiliate was 140 or about 12 new patients per month.

New patient = 8 hours/week New patient on insulin = 9 hours/week F/U patient =16 hours/week F/U insulin pt = 8 hours/ week Total = about 41 hours per week 41 hours/3 staff (RN, RD, BMS)* = 14 hours each or about .35 FTE

each. .35 FTE x 3= a little over 1 FTE total time per week.

*The time needed by type of staff will vary according to individual patient needs.

Summary of Sweet Success Services by

Service Description and Visit LengthThe purpose of this document is to provide a quick summary of the types of client categories, services usually rendered, and codes most often used when billing for these services. The summary descriptions refer to the average uncomplicated client. If the client seen has complications, the services codes may need to be modified for additional time spent. We recommend that you work with your billing and compliance department for consistent billing within your healthcare system and that you are meeting all of the criteria for billing as stated in the Current Procedural Terminology (CPT) manual using specific CPT codes. This document is intended for use with non-CPSP payers.

Type of Diabetes Length of Visit Type of VisitPreconception with:Type 1 DiabetesorType 2 Diabetes

2 hours Initial VisitObtain a thorough assessment of the individual lifestyle, capabilities, limitations, diabetes knowledge and skills, general health and obstetrical history. Provide the woman and her partner with adequate knowledge for: understanding the possible complications associated with diabetes and pregnancy; bringing about effective behavioral changes that will lead to improved diabetes self-care; making appropriate dietary, activity and insulin adjustments necessary for continued good control of diabetes; planning and early identification of pregnancy.

CPT Codes:99205 Initial office visit, new patient OR99245 Initial office consultation, new or established patient

Please note that you may bill only one of the above codes on the same date of service for the same beneficiary.

Preconception with:Type 1 DiabetesorType 2 Diabetes

1/2 – 1 hour Follow-up in one week to determine effectiveness of the care plan and make adjustments in diet, exercise, medications as needed. Review and discuss laboratory test, retinal exams, ECGs, etc., that were ordered at initial meeting in relation to specific individual case, presenting risk and options as they apply to client. Refer as indicated. Visit of 30 to 60

Type of Diabetes Length of Visit Type of Visitminutes of face-to-face time.

CPT Codes:99214-99215 Office visit, established patient OR99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

Pregnancy with:Type 1 DiabetesorType 2 Diabetes

2 hours Initial VisitObtain family, medical, and obstetrical history; institute individual self-care plan including medical nutrition therapy, exercise recommendations, blood glucose monitoring, medication adjustments, record keeping and psychosocial efficacy with the care plan. Make referrals as needed.

CPT Code:99245 Office consultation, new or established patient

Pregnancy with:Type 1 DiabetesorType 2 Diabetes

1 hour Follow-up in one week to determine effectiveness of the care plan, diet and weight gain appropriateness, make adjustments in diet, exercise, medications as needed.

CPT Code:99244 Office consultation, new or established patient

Pregnancy with:Type 1 Diabetes

orType 2 Diabetes

1/2 – 1 hour Subsequent follow-ups at one to two week intervals to clarify diet, blood glucose monitoring, review sick-day rules, provide additional information for breastfeeding/ infant feeding, future pregnancy planning and continued good health postpartum (i.e., nutrition, exercise, family planning).Further follow-up sessions will be determined by blood glucose control, adequacy of nutritional intake and weight gain, and presence of ketones in the urine, use of sick-day rules, and any red-flag psychosocial conditions.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

Type of Diabetes Length of Visit Type of VisitImpaired Glucose Tolerance (IGT) in pregnancy:one abnormal value on the 2 or 3 hr. Oral Glucose Tolerance Test (OGTT)

1 hour Initial VisitObtain family, medical, and obstetrical history; institute individual self-care plan including medical nutrition therapy, exercise recommendations, blood glucose monitoring, record keeping and psychosocial efficacy with the care plan.

CPT Code:99244 Office consultation, new or established patient

GDM:diet controlled in pregnancy

1 1/2 hours Initial VisitObtain family, medical, and obstetrical history; institute individual self-care plan including medical nutrition therapy, exercise recommendations, blood glucose monitoring, record keeping and psychosocial efficacy with the care plan. Make referrals as needed.

CPT Code:99245 Office consultation, new or established patient

GDM:Diet controlled in pregnancy

1 hour Follow-up in one week to determine effectiveness of the care plan, diet and weight gain appropriateness, make adjustments in diet, exercise, and determine if medications are needed.

CPT Code:99244 Office consultation, new or established patient

GDM:diet controlled in pregnancy

1/2 – 1 hour Subsequent follow-ups at one to two week intervals to clarify diet, blood glucose monitoring, review sick-day rules, provide additional information for breastfeeding/ infant feeding, future pregnancy planning and continued good health postpartum (i.e., nutrition, exercise, family planning).Further follow-up sessions will be determined by blood glucose control, adequacy of nutritional intake and weight gain, and presence of ketones in the urine, use of sick-day rules, and any red-flag psychosocial conditions.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

Type of Diabetes Length of Visit Type of VisitGDM:on oral hypoglycemicagent/s in pregnancy

2 hour Initial VisitObtain family, medical, and obstetrical history; institute individual self-care plan including use of oral hypoglycemic agents, medical nutrition therapy, exercise recommendations, blood glucose monitoring, record keeping and psychosocial efficacy with the care plan. Make referrals as needed.

CPT Code:99245 Office consultation, new or established patient

GDM:on oral hypoglycemicagent/s in pregnancy

1/2 – 1 hour Follow-up in one week to determine effectiveness of the care plan, diet and weight gain appropriateness, make adjustments in diet, exercise, and determine if medications working or need to switch to insulin.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

GDM:on oral hypoglycemicagent/s in pregnancy

1/2 – 1 hour Subsequent follow-ups at one to two week intervals to clarify diet, blood glucose monitoring, provide additional information for breastfeeding/infant feeding, future pregnancy planning and continued good health postpartum (i.e., nutrition, exercise, family planning). Further follow-up sessions will be determined by blood glucose control, adequacy of nutritional intake and weight gain, and presence of ketones in the urine, use of sick-day rules, and any red-flag psychosocial conditions.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

GDM:on insulin in pregnancy

2 hours Initial VisitObtain family, medical, and obstetrical history; institute individual self-care plan including medical nutrition therapy, exercise recommendations, blood glucose monitoring, initial insulin instruction, record keeping and psychosocial efficacy with the care plan. Make referrals as needed.

Type of Diabetes Length of Visit Type of VisitCPT Code:99245 Office consultation, new or established patient

GDM:on insulin in pregnancy

1 hour Follow-up in one week to determine effectiveness of the care plan, diet and weight gain appropriateness, make adjustments in diet, exercise, and determine if insulin adjustments are needed.

CPT Code:99244 Office consultation, new or established patient

GDM:on insulin in pregnancy

1/2 - 1 hour Subsequent follow-ups at one to two week intervals to clarify diet, blood glucose monitoring, insulin administration, provide additional information for breastfeeding/ infant feeding, reduction of risk for Type 2 diabetes, future pregnancy planning and continued good health postpartum (i.e., nutrition,exercise, family planning).Further follow-up sessions will be determined by blood glucose control, adequacy of nutritional intake and weight gain, presence of ketones in the urine, use of sick-day rules, and any red-flag psychosocial conditions.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

Postpartum follow-up 1/2 - 1 hour Assessment at 6 to 8 weeks postpartum to determine Medical Nutrition Therapy based on non-pregnant state, lactation needs, and other medical conditions requiring adjustment of the diet. Insulin adjustments for non-pregnant state, blood glucose monitoring, risk reduction counseling regarding weight control, exercise and follow-up testing for diabetes (if GDM). Emphasis on appropriate contraception and family planning for future pregnancies and to promote preconception planning.Referral to other providers as needed.

CPT Codes:99242-99244 Office consultation, new or established patient - select CPT code based on time with the patient and key components of care provided.

The remainder of this document is an example form of the Annual Affiliate Survey. The purpose of including it in this application is to

show what is required from our Affiliates and due at the end of January every year. The Annual Affiliate Survey can be completed online or via word document as seen below. Updated forms are always on our website

here: http://www.cdappsweetsuccess.org/Affiliates/Forms.aspx.

Please list the Primary CDAPP Sweet Success Affiliate site name that you are completing this Site Survey for. 1. Primary CDAPP Sweet Success Affiliate Name: Click here to enter text.

2. Have you been a CDAPP Sweet Success Affiliate in the past?☐ Yes☐ No

3. Are you completing the survey for more than (1) site?☐ Yes☐ No

4. If you answered “yes” to question 3, please list all additional sites that you are completing this survey for. Leave rows blank if they do not pertain to you.

Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.Name of Additional Satellite: Click here to enter text.

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4. Affiliate Medical Director Name: Click here to enter text.

5. Affiliate Address:Street Address + Suite, Building, or Room Number: Click here to enter text.City: Click here to enter text.Zip Code: Click here to enter text.

6. Please view your Affiliate Site(s) on our Affiliate Locator Online and tell us if you would like anything altered or added (e.g. phone number, website added, address change). Answer only the fields that apply and disregard this question if you are a new Affiliate.

Change my Affiliate or Satellite Name to: Click here to enter text.Change my Phone Number to: Click here to enter text.Change my Affiliate Address to: Click here to enter text.Add an email: Click here to enter text.Add a Website: Click here to enter text.Other (please type additional comments): Click here to enter text.

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As a reminder, the staff education requirement is: 8 webinars per calendar year for new staff 4 webinars per calendar year for continuing staff If you are a new Affiliate filling out a Site Survey for the first time, then all staff seeing patients must have completed 8 webinars this past calendar year.

1. Lead Staff Person Info:Name: Click here to enter text.Credential (RN, RD, BMS, MD, etc.): Click here to enter text.License #: Click here to enter text.Email: Click here to enter text.Direct Line: Click here to enter text.Best way to contact Lead Staff Person:

☐ Email☐ Phone

Lead Staff Person’s Completed Webinars (Check all that apply):☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD☐June 22, 2016 - Nutrition, Diabetes & Pregnancy After Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: Click here to enter text.

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2. Information for 2nd Staff Person:Name: Click here to enter text.Credential (RN, RD, BMS, MD, etc.): Click here to enter text.License #: Click here to enter text.Email: Click here to enter text.

2nd Staff Person’s Completed Webinars (Check all that apply):☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD☐June 22, 2016 - Nutrition, Diabetes & Pregnancy After Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: Click here to enter text.

3. Information for 3rd Staff Person:Name: Click here to enter text.Credential (RN, RD, BMS, MD, etc.): Click here to enter text.License #: Click here to enter text.Email: Click here to enter text.

3rd Staff Person’s Completed Webinars (Check all that apply):☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD☐June 22, 2016 - Nutrition, Diabetes & Pregnancy After Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE

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☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: Click here to enter text.

4. Information for 4th Staff Person:Name: Click here to enter text.Credential (RN, RD, BMS, MD, etc.): Click here to enter text.License #: Click here to enter text.Email: Click here to enter text.

4th Staff Person’s Completed Webinars (Check all that apply):☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD☐June 22, 2016 - Nutrition, Diabetes & Pregnancy After Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: Click here to enter text.

5. Information for 5th Staff Person:22 | P a g e

Name: Click here to enter text.Credential (RN, RD, BMS, MD, etc.): Click here to enter text.License #: Click here to enter text.Email: Click here to enter text.

5th Staff Person’s Completed Webinars (Check all that apply):☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD☐June 22, 2016 - Nutrition, Diabetes & Pregnancy After Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: Click here to enter text.

If you have more than 5 Staff Persons who completed their education requirement, please use the Supplement Staff Education List found on our website under Affiliates > Forms.

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This section reflects annual data for the clients served in the 2016 calendar year.Type of diabetes diagnosed at first CDAPP Sweet Success visit.

1. Clients seen in 2015 who carried over to 2016:Total Number (sum of Type 1, Type 2, and GDM): Click here to enter text.# of Type 1 Diabetes: Click here to enter text.# of Type 2 Diabetes: Click here to enter text.# of GDM: Click here to enter text.

2. New Clients seen only in 2016 (diagnosis at first CDAPP Sweet Success visit occurring in 2016)

Total Number (sum of Type 1, Type 2, and GDM): Click here to enter text.# of Type 1 Diabetes: Click here to enter text.# of Type 2 Diabetes: Click here to enter text.# of GDM: Click here to enter text.

3. Total Number of Clients seen in 2016Overall Number (adding Total Number from question 1 and 2 together): Click here to enter text.Overall Number of Type 1 Diabetes Seen (add type 1's from question 1 and 2): Click here to enter text.Overall Number of Type 2 Diabetes Seen (add type 2's from question 1 and 2): Click here to enter text.Overall Number of GDM Seen (add GDM's from question 1 and 2): Click here to enter text.

4. What can the CDAPP Sweet Success Resource and Training Center do to improve the services you provide to your patients? Click here to enter text.

5. Do you utilize the educational patient or provider resources we offer? If so, which specific resources? Click here to enter text.

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6. Looking back on the 2016 calendar year and the webinars we offered, are there any webinar topics that we did not cover that would be of interest to you for us to touch on in 2017? Click here to enter text.

7. If you have any additional comments or suggestions concerning the CDAPP Sweet Success Resource & Training Center, please add your notes here: Click here to enter text.

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