Improving Diabetes Management in Long-term Care

By: Valerie Lauer
Monday, March 2, 2015

A quality-improvement initiative in Texas sheds light on strategies for providing enhanced care to patients with diabetes.

Diabetes affects as many as one-third of patients in long-term care; however, due to the wide range of comorbidities and individual medical goals among this population, a single, standard treatment approach is not always the best response.

Addressing the Individual

The need for personalized medication management among elderly patients with diabetes drove Texas A&M University College of Nursing and Health Sciences Assistant Professor Cristi Day, DNP, FNP-C, APRN, ADM-BC, to develop the initiative, implemented at a nursing home in South Texas.

One potentially harmful standardized treatment approach involves sliding scale insulin (SSI). SSI is widely used, but American Geriatrics Society Beers Criteria identify it as an inappropriate treatment option for diabetes in seniors. Long-term monotherapy with SSI is linked to increased risk of hypoglycemia.

“[SSI] is reactive, so you are reacting to what the blood glucose was when you tested,” says Albert Barber, PharmD, CGP, FASCP, Director of Pharmacy Services for AlixaRX, which services patients in long-term- and post-acute-care facilities nationwide. “You have a number that was the result of the previous several hours and are now giving insulin that addresses glucose in the bloodstream over the forthcoming several hours. In a lot of ways, it prevents the nurse or prescriber from really addressing what the core issues are around glucose control.”

Recalibrating Treatment

Day set out to find a better approach. To combat the use of SSI and improve outcomes, she developed an evidence-based model of coordinated diabetes disease management with a focus on patient-centered care, combining recommendations from the AMDA: The Society for Post-Acute and Long-Term Care Medicine and the transaction process model of late nursing theory pioneer Imogene King.

A total of 22 participants were placed under the care of a dedicated diabetes care coordinator for a total of six months. The coordinator helped create individualized goals for patients, facilitated diabetes care training and made systemic improvements in how data was managed for better point-of-care access.

“Through changing some of the oral medications and eliminating SSI in those patients who didn’t need it, [we reduced] hypoglycemia cases to zero over the course of the study.”
— Cristi Day, DNP, FNP-C, APRN, ADM-BC, Assistant Professor, Texas A&M University College of Nursing and Health Sciences

Under the program, the number of patients who met hemoglobin A1c goals rose by approximately 50 percentage points. Additionally, there was a reduction in the number of SSI orders placed, from 61 percent of patients to 29 percent, as well as increased screening for diabetic retinopathy and improved staging and diagnosis of chronic kidney disease. In the final two months of the program, there were no recorded incidents of hypoglycemia.

There are potentially broad benefits, Day says.

“When glucose is controlled, there are fewer complications,” she says. “We know when outcomes are improved, costs go down.”

Day is working to expand the study’s reach — replicating it in similar facilities, exploring the impact her model can have on patient quality of life and clarifying the potential benefits of having a dedicated diabetes manager on staff, including enhanced outcomes, reduced orders and improved staff efficiencies.