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On a Friday afternoon, David, a 15-year-old mentally challenged adolescent seen for evaluation by an endocrinologist, was diagnosed with type 1 diabetes mellitus and diabetic ketoacidosis. During the office visits, his blood glucose was more than 350 mg/dl and urine ketones were moderately large. Recent history identified a 15-lb weight loss over the past 2 weeks, along with the signs of hyperglycemia: polydypsia, polyphagia, polyuria, tiredness, and easily fatigued. The family requested alternative options to hospitalization due to David's anxiety reactions. The physician administered 10 units of intermediate insulin during the office visit and contacted the insurer for coverage of potential alternative interventions and referral.


David was referred to the Diabetes Case Management and Education Home Care Program at Level III intensity, and a telephone assessment and support call was scheduled for Friday evening and a 6:00 a.m. visit for Saturday morning. Visits would be provided twice a day along with at least twice-a-day telephone support calls for the initial 5 days, with one extra visit approved for Saturday and Sunday if needed. The family was to obtain insulin and supplies from the local pharmacy, and the insurance case manager was to arrange delivery of urine ketone sticks and a blood glucose monitor with supplies Friday evening.


Prior to acceptance into the program, it was mutually agreed by all parties that David would be hospitalized if he began vomiting, became progressively lethargic and somnolent, or supplies were unable to be obtained and available in the home. All family members involved in providing David's care would be present at visits until they became independent in diabetes management skills. Specific goals, based on standards of care, were established for safe and effective resolution of ketoacidosis and glucose toxicity, insulin therapy, blood glucose range, hydration and dietary management, and diabetes survival skills education. The endocrinologist on-call over the weekend agreed to respond in a timely manner to clinical reports and requests for changes in insulin dose based on blood glucose and urine ketone results and trends.