Title: A Unique Guide to Improve Diabetes Management in LongTerm Care Facilities
1A Unique Guide to Improve Diabetes Management in
Long-Term Care Facilities
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Roberta Meyers, MD, MPH
- Hennepin County Medical Center
- roberta.meyers_at_hcmed.org
- Laurel Reger, MBA
- Minnesota Diabetes Program
- laurel.reger_at_state.mn.us
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3A Unique Guide to Improve Diabetes Management In
Long-Term Care Facilities
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Objective To update a long-term care (LTC) guide
to assist front-line LTC staff in effectively
managing diabetes
4Project Contributors
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Jamie Barber, RN, CNP
- Shirley Conn, RN
- Jodie Duntley, RN, CNP, CDE
- Randi Hansen, RN,C
- Sidney Jones, MD
- Roberta Meyers, MD, MPH
- Jennifer Peterson, RD, CDE
- Joanne Peterson, RN, CDE
- Laurel Reger, MBA
- John, St. Peter, PharmD
- Kathleen Woo-Rippe, MD
- Diana Noller, RN, CDE
5Diabetes is Prevalent in LTC
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 25 of LTC facility residents have diabetes
- Tariot PN, Ogden, AM, Cox C, et al. Diabetes and
dementia in long-term care. J Am Geriatrc Soc
199947423-439. - Duffy RE, Mattson BJ, Zack M. Co morbidities
among Ohios nursing home residents with
diabetes. J Am Med Dir Assoc 20056383-389. - Zarowitz BJ, Tangelos EG, Hollenack K, et al. The
application of evidence-based principles of care
in older persons (issue 3) Management of
diabetes mellitus. J Am Med Dir Assoc
20067234-240. - Meyers RM, Broton JC, Woo-Rippe KW, et al.
Variability of glycosylated hemoglobin values in
diabetic patients living in long-term care
facilities. J Am Med Dir Assoc. 20078511-514. - Sims J. Minimum Data Set Report. Minnesota Dept.
of Health, 2009 personal communication.
6LTC Guideline Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 1991 Minneapolis/St. Paul Diabetes Educators
(MSDE) convened 44 member task force - Objective assess needs of LTC residents with
diabetes - Key issue lack of care standards
7LTC Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 1991-1992 Guidelines developed
- 1992 Guidelines distributed to all 445 LTC
facilities in Minnesota - 2/3 of 445 LTC facilities responded to a survey
and strongly agreed the guidelines were
understandable, thorough and useful for staff
education and care
8LTC Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 1996 Quality Improvement (QI) Initiative
- Objective pilot a QI process to implement
guidelines in 2 LTC facilities - QI process adapted from successful approach for
primary care settings - Involved staff training and data collection
9LTC Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 1996 QI Pilot
- 191 residents with diabetes were affected
- Effective system changes made within 1 year
- Developed new policies/protocols for glucose
monitoring, hypoglycemia - Reduced hyper- and hypoglycemia incidents,
severity of foot ulcers, and resident sick days
10LTC Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 1996 QI Pilot
- Challenges
- Staff turnover
- Lack of a diabetes registry and computer skills
- Lack of evidence, and thus, little physician
support for care LTC recommendations
11LTC Initiative
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- 2000 4th revision of the LTC Guidelines
- 2005 Working group convened to update for a 5th
edition - Minneapolis-St. Paul Diabetes Educators
- Hennepin County Medical Center
- Minnesota Diabetes Program
122005-2008 Revision Process
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Reviewed existing guidelines
- Defined target audience
- Assigned tasks
- Reviewed assignments (biweekly meetings/email)
- Reached consensus
- Peer-reviewed by local experts
- Implemented web-based Guide
132005-2008 Revision Process
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Reviewed existing diabetes guidelines
- Examined recommendations for general populations
for appropriateness to LTC facility residents - Recognized that diabetes patients in LTC require
diverse treatment strategies
142005-2008 Revision Process
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Defined target audience
- Shifted from prescriber providers (NPs, MDs) to
direct care staff (LPNs, NAs) who provide most of
the patient care in LTC facilities - Product became a Guide, not Guidelines
- Required first hand knowledge of the LTC
environment
15Diabetes in LTC Facilities
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Three distinct LTC groups recognized
- Sub-acute patients evidence from acute care
regarding benefits of tight control may apply - Young residents evidence that tight control
reduces long-term complications may apply - Traditional residents burdens of tight control
outweigh benefits
16- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
LTC vs. Outpatient vs. Hospital
- LTC patients
- Medically complex, multiple chronic diseases,
multiple medications - Some need more intensive control, others not
- May be changing acutely or may be stable
- In a monitored setting
- May be dependent in eating
17Lack of evidence for LTC
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Numerous guidelines for general population
- American Diabetes Association
- American Association of Clinical Endocrinologists
- VA/DoD clinical practice guideline
- Institute for Clinical Systems Improvement
- National Guideline Clearinghouse
(www.guideline.gov)
18Guidelines for Geriatrics/LTC
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Empiric/expert opinion rather than evidence-based
- Written primarily for providers/prescribers
- AMDA Managing Diabetes in the Long Term-Care
Setting (www.amda.com) - AGS California Healthcare Foundation/American
Geriatrics Society Panel on Improving Care for
Elders with Diabetes. Guidelines for improving
the care of the older person with diabetes
mellitus. J Am Geriatr Soc 200351S265-S280. - European Diabetes Working Party for Older People.
Clinical Guidelines, 2004, (www. eugms.org)
19What were the challenges?
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Lack of evidence, although consensus based
guidelines exist - Lack of uniform definitions what is
hypoglycemia in a LTC resident? - LTC environment
- Non-licensed staff
- Application of medical model to residentially
focused environment
20What were the challenges?
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- How to provide useful information when patients
require individualized treatment goals based on
unique circumstances - How to develop materials appropriate and useful
to direct care/non-licensed staff
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23Developing Targets
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- While there are no established A1c goals for the
elderly, community standards recommend
maintaining an A1c between 7-8 depending on the
predicted life expectancy8 is a reasonable goal
for frail and physically compromised residents.
If the estimated life expectancy is thought to be
more than five years, or if the resident in the
LTC facility is not elderly, an A1c goal of
6-7.5 is reasonable in relatively healthy
adults. - Diabetes Management in Long Term Care
Facilities a Practical Guide, 5th Ed., 2008
24Next Steps
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
- Translation into other languages
- Adapt for assisted living/home care
- Adapt for continuing education credits
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33Tool Kit Section C
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
34Look for us on our websiteLTCdiabetesguide.org
- MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS