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A Unique Guide to Improve Diabetes Management in LongTerm Care Facilities

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laurel.reger_at_state.mn.us. MSDE. MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS ... Laurel Reger, MBA. John, St. Peter, PharmD. Kathleen Woo-Rippe, MD. Diana Noller, RN, CDE ... – PowerPoint PPT presentation

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Title: A Unique Guide to Improve Diabetes Management in LongTerm Care Facilities


1
A Unique Guide to Improve Diabetes Management in
Long-Term Care Facilities
  • MSDE
  • 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

2
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3
A Unique Guide to Improve Diabetes Management In
Long-Term Care Facilities
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
  • Objective To update a long-term care (LTC) guide
    to assist front-line LTC staff in effectively
    managing diabetes

4
Project Contributors
  • MSDE
  • 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

5
Diabetes is Prevalent in LTC
  • MSDE
  • 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.

6
LTC Guideline Initiative
  • MSDE
  • 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

7
LTC Initiative
  • MSDE
  • 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

8
LTC Initiative
  • MSDE
  • 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

9
LTC Initiative
  • MSDE
  • 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

10
LTC Initiative
  • MSDE
  • 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

11
LTC Initiative
  • MSDE
  • 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

12
2005-2008 Revision Process
  • MSDE
  • 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

13
2005-2008 Revision Process
  • MSDE
  • 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

14
2005-2008 Revision Process
  • MSDE
  • 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

15
Diabetes in LTC Facilities
  • MSDE
  • 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
  • MSDE
  • 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

17
Lack of evidence for LTC
  • MSDE
  • 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)

18
Guidelines for Geriatrics/LTC
  • MSDE
  • 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)

19
What were the challenges?
  • MSDE
  • 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

20
What were the challenges?
  • MSDE
  • 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

21
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22
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23
Developing Targets
  • MSDE
  • 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

24
Next Steps
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
  • Translation into other languages
  • Adapt for assisted living/home care
  • Adapt for continuing education credits

25
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26
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

27
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

28
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

29
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

30
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

31
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

32
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

33
Tool Kit Section C
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS

34
Look for us on our websiteLTCdiabetesguide.org
  • MSDE
  • MINNEAPOLIS-ST. PAUL DIABETES EDUCATORS
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