Assessment of Inpatient Diabetes Care Management and Education in Wisconsin Critical Access Hospitals

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1 Assessment of Inpatient Diabetes Care Management and Education in Wisconsin Critical Access Hospitals Authors: The Critical Access Hospital Diabetes Project Workgroup vember 2006

2 TABLE OF CONTENTS INTRODUCTION... 3 PART 1: SUMMARY OF FINDINGS... 7 SECTION A: GENERAL INFORMATION... 7 SECTION B: INPATIENT CARE... 7 SECTION C: INPATIENT STAFF CONTINUING EDUCATION... 8 SECTION D: INPATIENT DIABETES EDUCATION... 9 SECTION E: BARRIERS SECTION F: DISCHARGE PLANNING SECTION G: COMMUNITY OUTREACH SECTION H: QUALITY IMPROVEMENT SECTION I: INPATIENT DATA PRACTICES SECTION J: MISCELLANEOUS PART 2: CONCLUSIONS AND RECOMMENDATIONS PART 3: DETAILED ANALYSIS FINDINGS SECTION A: GENERAL INFORMATION SECTION B: INPATIENT CARE SECTION C: INPATIENT STAFF CONTINUING EDUCATION SECTION D: INPATIENT DIABETES EDUCATION SECTION E: BARRIERS SECTION F: DISCHARGE PLANNING SECTION G: COMMUNITY OUTREACH SECTION H: QUALITY IMPROVEMENT SECTION I: INPATIENT DATA PRACTICES SECTION J: MISCELLANEOUS METHODS LIMITATIONS REFERENCES RESOURCES ACKNOWLEDGEMENTS APPENDIX 1: ASSESSMENT TOOL

3 INTRODUCTION Diabetes: A Major Health Problem The National Centers for Disease Control and Prevention (CDC) proclaims that diabetes is disabling, deadly, and on the rise. National statistics indicate that more than 20.8 million Americans have diabetes; 6.2 million of these don t even know they have the disease. The number diagnosed with diabetes is increasing at an alarming rate, doubling over the past 15 years. New evidence shows that 1 in 3 Americans born in 2000 will develop diabetes sometime during their lifetime. In addition to the millions with diabetes, an estimated 41 million U.S. adults aged years have a condition called pre-diabetes, meaning their blood sugar levels are elevated, but not high enough to be classified as diabetes. These people are at high risk for developing type 2 diabetes in the future. (1, 2) Statistics indicate that people with diabetes have a 2.2 to 4-fold increased rate of hospitalization and incur a two-fold increase in costs for inpatient care than someone without diabetes. (3) In 2002, the inpatient cost for people with diabetes was $40.3 billion. (4) Since most people with diabetes are admitted to the hospital for comorbid conditions, not primarily for diabetes treatment, diabetes management is usually not the focus of inpatient care. Diabetes was listed as a diagnosis in 12.4% of hospital discharges in 2000; however, since diabetes is often a secondary diagnosis, it is likely underreported in discharge records. Diabetes was listed as a principal diagnosis in only 8% of those 2000 hospitalizations. It is estimated that discharge diagnosis codes may underestimate diabetes in hospitalized patients by as much as 40%. In addition, some estimates indicate that for every two patients in the hospital with known diabetes, there may be an additional one with newly noted hyperglycemia. Reports indicate as many as 60% of patients with no prior history of diabetes who are found to have hyperglycemia during hospitalization are likely to have diabetes at follow-up testing. (5, 6) Evaluation of hyperglycemia in hospitalized patients presents an opportunity for early detection and management. Quality of Diabetes Care Over the past few years, increasing national attention has been focused on improving diabetes care in the outpatient setting through the implementation of evidenced-based guidelines and promotion of chronic care approaches that emphasize prevention and improving outcomes. The value of tight glycemic control is now widely accepted for outpatient management of diabetes. However, little direction has been provided on useful approaches to improve inpatient diabetes care delivery, even though the national burden for inpatient diabetes care is significant. Recently the American College of Endocrinology (ACE), along with the American Diabetes Association (ADA) released a joint consensus statement with recommendations for improving inpatient diabetes and glycemic control. The statement referred to major studies that showed a strong association between hyperglycemia and poor clinical outcomes among hospitalized patients and concluded that multiple institutional and attitudinal barriers still exist to improved care that have created a significant and growing gap between what we know and what we do. (7) Their consensus statement identifies strategies for implementing improved diabetes management in hospitalized patients. Some of their recommendations include: An appropriate level of administrative support for the long-term investment of time and resources 3

4 Establishment of a multi-disciplinary steering team to promote the development of initiatives Assessment of current processes, quality of care, and barriers to necessary changes in practice Development and implementation of interventions, such as standardized order sets, protocols, policies, and algorithms Creation of educational programs for all hospital personnel caring for people with diabetes Evaluation systems to track hospital glucose data on an ongoing basis and guide quality improvement Plans for a smooth transition from hospital to outpatient care with appropriate diabetes management and follow-up for patients with newly recognized glucose abnormalities The ACE/ADA recommendations are similar to those identified in the Institute of Medicine s (IOM) 2001 report, Crossing the Quality Chasm. The IOM report identified major gaps in the quality of today s healthcare and made the following recommendations for organizational redesign: Better systems of finding best practices and assuring best-known clinical models Better use of informational technology to improve access to information and to support clinical decision-making More consistent development of effective teams and teamwork Improved workforce knowledge and skills Better coordination of care among services and settings, both within and among organizations, especially with respect to the care of people with chronic illnesses More sophisticated, extensive, and informative measurement of performance and outcomes. (8) The good news is that diabetes is controllable. Research shows that many diabetes-related complications and hospitalizations are preventable with improved care delivery, early detection, and better self-management education. For example, studies have demonstrated that use of a team to provide inpatient care can reduce length of stay and the rate of recurrent hospitalization, that good glycemic control can improve outcomes, and that medication errors can be reduced through the use of protocols. Outreach visits and academic detailing with respected experts and local champions have been shown to lead to improvements in professional practice. (9-27) Rapid advances in health care over the past decade have created significant challenges to hospital staff who serve as generalists in caring for patients with a wide array of complex health conditions, requiring ever expanding needs for ongoing continuing education and competency. Although diabetes is mainly a self-managed disease, CDC reports indicate that people with diabetes still receive little education on how to self-manage their disease. Shorter hospital stays, higher acuity levels, and time limitations often make it difficult to provide inpatients with essential self-management training. Discharge planning that is deliberate and comprehensive, including an assessment of social and economic issues as well as referrals for necessary followup care and education, can impact the patient s ability to manage their care safely at home and prevent re-hospitalization. 4

5 The National Diabetes Quality Improvement Project (DQIP) and state-led initiatives with Wisconsin s health maintenance organizations and community health centers have led to improvements in diabetes-related outcome measures in the outpatient setting. These initiatives rely heavily on administrative support, the use of guidelines, protocols, and diabetes teams, provision of self-management support, ongoing staff education, community linkages, and information technology and surveillance systems that are able to generate data to facilitate proactive care and evaluation of quality of care. Collaborators use a learning model, regularly sharing strategies, experiences, and resources with one another. This collaborative model may also serve to be a useful approach for improving diabetes care delivery in the hospital setting. Project to Evaluate Diabetes Care in Rural Hospitals This year the Wisconsin Office of Rural Health (WORH) embarked on a project to begin to evaluate inpatient diabetes care, specifically addressing hospitals in rural areas. The WORH has been providing technical assistance to help hospitals achieve critical access hospital (CAH) status and develop rural networks to improve access to care through the Flex Program since Rural hospitals that meet specific federal requirements qualify for this special designation as a critical access hospital. This designation provides a different reimbursement system that is intended to improve their financial status and reduce hospital closures. Some of the reported benefits, in addition to potential financial advantages, include flexible staffing, access to technical assistance through the Flex Program, and a focus on the community. The critical access hospitals must operate in rural areas, have no more than 25 beds, and have an annual average length of stay of no longer than 96 hours. While their existence is important to preserving access to care in rural areas, these small hospitals are particularly challenged in caring for a wide array of complex health conditions with limited resources. The WORH provides technical assistance with staff training, collaboration, and evaluation activities. The Program also provides mini-grants for the development of community coalitions, several recently allocated for improving diabetes care. The WORH collaborated with the Wisconsin Diabetes Prevention and Control Program (WDPCP), the Wisconsin Hospital Association (WHA), and representatives from several critical access hospitals to implement this project to assess inpatient diabetes care. The project objectives are to: Identify barriers and challenges that impede the delivery of quality inpatient diabetes care management and education services in critical access hospitals Provide recommendations to help hospitals meet identified diabetes care challenges Identify potential resources and linkages that may help support inpatient diabetes care and quality improvement activities A review of the literature and contact with other state Diabetes Prevention and Control Programs across the nation revealed that little is known about the state of diabetes care delivery within critical access hospitals. The collaborators developed an assessment tool that was distributed to the administrators of 58 critical access hospitals throughout Wisconsin. Participation was voluntary. Each administrator was encouraged to have the person who was likely to know the most about how inpatient 5

6 diabetes care management and education services are handled at their facility complete and return the assessment tool within 30 days. Respondents had the option to complete the assessment tool either electronically or by hand. A private contractor was hired to coordinate the workgroup activities, develop materials for review, coordinate the distribution of the assessment tool, analyze the data, prepare reports, and maintain confidentiality of submitted information. The workgroup reviewed the summary of assessment findings and developed recommendations for this report. 6

7 PART 1: SUMMARY OF FINDINGS Forty-six of fifty-eight critical access hospitals completed and returned an assessment tool, for a 79% response rate. A summary of findings is reported for each section of the assessment tool. A detailed analysis of the data is included in Part 3: Detailed Analysis Findings. Section A: General Information Information received for this section of the assessment shows: Respondents had an average length of employment at their facility of years, with a wide range of 1 month to 39 years. Twenty (43%) indicated there was a staff person specifically identified to coordinate care for inpatients that have diabetes; approximately half of these have advanced training in diabetes care management. The average length of time the coordinator has been providing diabetes care services was 8 years, with a range of 1 year to 20 years. The defined role of the inpatient diabetes coordinator varied widely from: providing minimal education on a need to know basis to the provision of more comprehensive diabetes education, including responsibilities for staff education and the development of guidelines and policies. The specific number of other staff members who provide diabetes care and/or education was unable to be determined due to a flaw in the survey tool. However, other survey data shows that 18 of the 46 (39%) participating hospitals had access to at least one certified diabetes educator (CDE) for inpatient services. Many respondents indicated that most of their staff members that are not CDEs had not received continuing education related to diabetes within the past 3 years. Actual numbers are not available. Few respondents reported having access to diabetes-related information for their facility. 23 respondents (50%) reported data on admissions in the past year for diabetic ketoacidosis (DKA); the average was 3.22 admissions and the range was 0-9 admissions 16 respondents (35%) reported data on admissions in the past year for hyperosmolar hyperglycemic state; the average was 2.13 admissions and the range was 0-12 admissions 24 respondents (52%) reported data on average length of stay for a person with a primary diagnosis of diabetes; the range was 2.80 days and the range was 0-5 days 17 respondents (37%) reported data on admissions for average length of stay for a person with a secondary diagnosis of diabetes; the average was 3.40 days; and the range was 2-5 days Only 8 respondents (17%) reported data on the percent of patients with diabetes who are readmitted within 30 days; the average was 14% and the range was 0% to 66% Section B: Inpatient Care Protocols Responses showed wide variation in the use of standardized protocols to direct the provision of inpatient care. The most widely used protocols reported are: hypoglycemia (80%), insulin sliding scale (72%), intravenous insulin infusion (67%), and bedside blood glucose monitoring (61%). 7

8 Other protocol use was reported as: hyperglycemia (50%), immunization standing orders (48%), diabetic ketoacidosis (39%), pre-op pertaining to diabetes (22%), standing admission orders specific to diabetes (17%), insulin correction dose (15%), hyperosmolar hyperglycemic state (11%), screening inpatients for diabetes (11%), insulin pump protocols (11%), post-op pertaining to diabetes (9%), discharge (9%), and referral to specialty care (4%). One respondent indicated they also use a protocol for diabetes education. All 46 respondents indicated they were interested in receiving the recommendations for inpatient diabetes care that are being developed by the Wisconsin Diabetes Advisory Group; the majority (85%) indicated that they were willing to work to implement them at their hospital. Insulin Therapy About 2/3 of respondents (67%) reported that patients admitted to their hospital who required insulin therapy would most likely continue to stay at their hospital, as opposed to being transferred elsewhere. Children with Type 1 Diabetes About half of respondents (54%) reported that their hospital admits and treats children with type 1 diabetes. Nineteen reported information on the number of children with type 1 diabetes who were admitted in the past year; the average was 1.5 and the range was 0-5. Multidisciplinary Team Only 26% of respondents reported having a designated inpatient multidisciplinary diabetes team. Team members listed most often included: RN (100%), the pharmacist (100%), the primary care provider (93%), and an RD (93%). Social worker was reported by 42%. Admitting Physician All 46 respondents indicated that the admitting physician assumes responsibility for the patient s diabetes care management while hospitalized. Hospitalist Only 2 respondents (4%) reported that their facility uses hospitalists. Access to Diabetes Specialists Half of the respondents reported having access to diabetes specialists. The numbers reporting specialty access by type were: specialist provides continuing education to hospital staff (15), telemedicine consults (8), specialist makes on-site visits to the inpatients (6), and internet/web consults (5). Nine respondents identified other specialty access as: telephone consults (3), certified diabetes educator (1), contacting Madison doctors (1), a specific clinic (1), specialist makes on-site visits to outpatients (1), podiatry (1), and referral to specialist from primary MD (1). Section C: Inpatient Staff Continuing Education The most widely used methods reported for inpatient staff continuing education were: time off for conferences (89%), internet (83%), in-house seminars (76%), on-line access to education 8

9 (76%), and consultation with diabetes experts (54%). Less used methods were: competencybased in-house modules (41%), grand rounds and case reviews (22%), and telemedicine (17%). Three respondents listed other methods used as: satellite access, members of the advisory board, and physician updates. Only 10 respondents (22%) reported that their hospital requires inpatient staff participation for continuing education related to diabetes care management. Section D: Inpatient Diabetes Education Admission Process Sixteen respondents (35%) reported there was a routine method during the admission process for hospital staff to ask whether the person with diabetes has ever had diabetes education. Diabetes Knowledge/Skills Seventeen respondents (37%) reported there was a method to document each inpatient s level of diabetes knowledge and skills. Resources for Diabetes Education: Major resources for inpatient diabetes education identified were: voluntary organizations (76%), professional organizations (57%), government (57%), and pharmaceutical companies (57%). Lesser reported sources were: the American Association of Diabetes Educators (43%), the International Diabetes Center (41%), standardized diabetes education curriculum (41%), and purchase from private health education company (30%). Several respondents listed other resources as: updates from a clinic, Logicare, and self-made. Nineteen respondents (41.3%) reported that they use a standardized diabetes education curriculum. These curricula were identified as: American Diabetes Association (5), International Diabetes Center (4), locally developed (3), and a health education company [Logicare] (3). The other four did not specify their curriculum. Approximately half (53%) reported they had a process to periodically review patient education materials for accuracy and relevancy; the average review frequency was 10 months. Those indicating they had a review process were asked to describe the process. Major responses indicated that reviews were done through a multidisciplinary committee, patient education committee, advisory committee, a CDE, a vendor, and through affiliations with major clinics. Other responses were non-specific. Diabetes Education Topics Taught The topics reported as most frequently taught to inpatients prior to discharge were: hypoglycemia, medication, nutrition management, self-monitoring of blood glucose, contacting the provider, and insulin adjustment. Methods for Diabetes Education The most widely used methods reported for providing diabetes education were: individual inpatient instruction (92%), outpatient referral (80%), preprinted handouts only (76%), and videos (67%). Less used methods were: support group (41%), patient access to the Internet in 9

10 the hospital (28%), CD ROM/DVD with inpatient computer access (13%), group inpatient instruction (4%), and cassette tapes (2%). Documentation Twenty respondents (61%) reported the use of standardized methods to document inpatient diabetes care and education. Section E: Barriers Barriers to providing inpatient diabetes care management and education services that were cited the most were: High acuity levels and short hospital stays, limiting patients learning capacity (74%) Lack of diabetes specialty physicians to consult with on inpatient issues (70%) Lack of protocols for inpatient diabetes care management (67%) Lack of an inpatient diabetes team to coordinate care (67%) Lack of available, trained diabetes educators for inpatient care and consultation (65%) Lack of documentation protocols (59%) Inadequate staffing resulting in lack of time to effectively assess and educate patients (54%) Lack of knowledge about insulin protocols and newer medications (54%) standardized diabetes education curriculum (52%) Lack of computerized patient chart/records (52%) t enough access to staff continuing education opportunities (46%) Section F: Discharge Planning The RN and social worker were the staff most frequently listed as responsible for discharge planning for inpatients with diabetes. The primary care provider, RD, and pharmacist were listed less frequently. Six respondents listed others involved in discharge planning as: discharge planner, utilization review, diabetes educator, care management, clinical coordinator, and dietary manager. The majority of respondents (91%) reported that their hospital does not use standardized protocols for diabetes-related discharge orders. Respondents were also asked to describe their discharge planning process. Their responses are summarized in Part 3: Detailed Analysis Findings, Section F. Community Referral for Other Diabetes Education and Resources: Thirty-eight respondents (83%) reported that they refer patients with diabetes to education programs or other resources in the community. Individual responses regarding their referral process varied and are summarized in Part 3: Detailed Analysis Findings, Section F. Barriers Barriers to referrals for community diabetes education that were cited the most were: Patient lack of interest or unwillingness to attend diabetes education (63%) Lack of perceived value of diabetes education by patients (59%) Physician does not refer (48%) 10

11 Patients lack sufficient insurance coverage for diabetes education (43%) Distance patient must travel to receive diabetes education (43%) Personal cost to patients for receiving diabetes education in the community (39%) Lack of public transportation to help patient get to diabetes education (37%) Community health practices are more crisis-oriented than preventive (37%) Other barriers and/or comments listed by respondents were: Number of hours allowed versus number of hours needed (reimbursement) Minimum number of patients so is difficult to achieve appropriate staff competence Lack of perceived value or need by nursing Only done if ordered by provider Lack of community diabetes education services Work conflicts added to class/education schedule not convenient for patient Physicians do not value education as a team effort Pre-diabetes not covered budget for diabetes education team Fear and misunderstanding of diabetes Medicare guidelines not allowing patient to be seen by RN and RD on same day. We live in a rural area where transportation is often a challenge to arrange. Some persons travel over 40 miles one way to get to appointments. It s a senseless Medicare rule that needs revisiting. Gas prices and asking patients to make separate or frequent trips hinder quality care delivery. It should be noted that a high number of respondents indicated don t know/not sure to each of the barriers listed in this section. The range of don t know responses ranged from 13% to a high of 57% for some of the barrier choices. Section G: Community Outreach The majority of respondents (72%) reported that their hospital offers outreach services to increase diabetes awareness and promote diabetes prevention in local community settings. The majority of these reported using health fairs and community events More than half of these reported using worksites and/or employee wellness programs, newspaper articles/radio messages, community diabetes support groups, diabetes community screening programs, and home care Almost half reported using hospital newsletters About a third reported using meal-site programs community/fraternal organizations and schools Few respondents reported using churches or grocery stores/malls Other settings added by respondents were local cable/tv program and bus rides organized for people to attend local diabetes expo with pick up from several sites Collaboration Only 17% of respondents reported that their hospital was involved in community diabetes-related health care collaborations. 11

12 The names of the community collaborations are not included in this report due to confidentiality. Various community organizations reported as involved in collaborations include: hospitals, local clinics, UW Extensions, local county public health and human service departments, Lions clubs, Big Brothers/Big Sisters, schools, family planning, county circuit court, parent resource centers, police/sheriff departments, child care organizations, head start, clergy associations, hospices, commissions on aging, and community members with diabetes. General activities reported for their current collaborative activities were: Providing information via news media and billboards on highways Conducting health fairs and community events Screening and education at worksites Community nutrition and physical activity coalitions working on the root causes of diabetes lifestyle choices Promoting individual and family well-being Assessing the needs of the community Improving inpatient and outpatient diabetes education Identifying quality improvement efforts and desired outcomes Working closely with health systems and following guidelines and protocols developed based on best practice Offering patient management tools for clinical practice to improve diabetes care at the hands of the provider Tracking blood pressure, LDL, and diabetes quality standards Section H: Quality Improvement Diabetes Measures Few respondents (9%) reported that their hospital had a formal quality improvement program that included inpatient diabetes care outcome measures; 17% of respondents reported don t know/not sure. respondents reported any specific diabetes-related inpatient measures being tracked by their hospital. One respondent indicated they only measure outpatient at this point. Satisfaction Six respondents (13%) reported their hospital assesses patient satisfaction with inpatient diabetes care and education services; 8 respondents (17%) indicated don t know/not sure. Three respondents provided additional comments regarding assessment of patient satisfaction with diabetes care management and education services. Comments were: Just started checking patient follow-up rates, satisfaction, and inpatient length of stay This is an assessment of all inpatient care, not specific to diabetes Patients are given number to call with problems, concerns, and satisfaction with program Section I: Inpatient Data Practices New Cases of Diabetes Only 3 respondents (7%) reported they use a specific process to identify new cases of diabetes in inpatients. Two listed initial nursing assessment and the other listed diagnosis by health care provider. 12

13 Medical Records Twenty-two respondents (48%) reported they use paper records for inpatient care; four (9%) reported using electronic records; and twenty (43%) reported using a combination of paper and electronic records. Database Nineteen respondents (41%) reported having a system, such as a database or electronic medical record that can identify inpatients that have diabetes, seventeen (37%) said they did not, and ten respondents (22%) indicated they didn t know or were not sure. System names reported were: CSPI, Cerner, Meditech, Phamous, HBIC, HMS, PCI, Epic, IMPACT, and ABS Diagnostic. Six respondents indicated that diabetes care and education data were entered into a computer program for monitoring and evaluation purposes. Responses given for who enters data into the system were: RN (6), RD (3), PCP (2), pharmacist (1), psychologist (1), and social worker (1). Queries Responses to the question asking about the types of queries their system can generate is difficult to analyze, since the responses outnumber those who initially reported having a database or system. Since many reported don t know/not sure as their answer, only those who indicated that they can generate a specific query are reported in the summary below. Track inpatient glycemic management (7) Identify new cases of diabetes (6) Assist with disease surveillance (5) Provide inpatient diabetes-related data for QI activities (4) Track inpatient education services (4) Track inpatient outcomes of care (3) Help coordinate referrals (2) Identify persons who may have pre-diabetes (2) Identify need for follow-up care (1) Identify the need for outreach services (1) Several of those who reported they could generate a query to track inpatient glycemic management indicated that the report only provides individual-level summary data, not aggregate (population-level) reports. Nine respondents (29%) reported that another mechanism is used to monitor inpatient diabetes care; all of those nine reported chart review. Section J: Miscellaneous Education Program Recognition Fifteen respondents (33%) reported that their hospital has recognition by the American Diabetes Association (ADA) for its diabetes education services. 13

14 Twelve respondents (38%) indicated that their hospital was interested in applying for ADA recognition for diabetes education services. Eleven respondents indicated don t know/not sure. Nineteen respondents (41%) reported their hospital collaborates with a local ADA recognized diabetes education program. Five indicated don t know/not sure. Listserv Twenty-nine respondents (63%) indicated an interest in participating in a diabetes listserv to share strategies and resources with colleagues. Fifteen respondents (33%) indicated don t know/not sure. Only two respondents indicated no. Specific Training or Resources Requested Respondents were asked to identify specific training and resources that would help their hospital improve its diabetes care management and education services. General comments reported have been combined and are summarized below into major categories of the chronic care model. Research has shown that interventions that include elements of the chronic care model improve processes of care and clinical outcomes (28). Organizational Support Access to a certified diabetes educator Promotion of diabetes education to hospital staff More departments to coordinate patient care and get ADA certified A budget that would cover expenses such as teaching materials, materials purchased for our community meetings, annual diabetic educators convention Increased staffing hours to effectively provide inpatient diabetic management; several respondents reported that they do not routinely see all inpatient diabetics with current staff hours and have difficulty meeting the needs of current outpatients Financial resources and funding for education resources and software Clinical Information Systems and Evaluation Ways to track without computerized medical records access Computerized system which has the plan of care incorporated into EMR Easy way to collect outcome data Quality assurance program Mechanism for periodic evaluation and updating of the materials we do have Up-to-date materials for evaluation of the patient's knowledge of diabetes care Decision Support Evidence-based protocols for management, medication alteration, insulin drips, glucose monitoring, correction-dose insulin, insulin pumps, diabetes education, referrals, documentation Support in revamping our system and resources Diabetic education specialist to inservice education training with staff nurses Training on evidence-based practice for diabetes Physician education on new meds and approaches 14

15 On-site training and guest speakers Staff updates and newsletters Delivery System Design Our own diabetic champion to review protocols and bring them back to staff Better coordination between staff Articles on benefit of inpatient CDE to justify cost savings Policies/procedures on when to consult CDE for inpatients A systematic education program with appropriate staff training and discharge planning to improve the consistency and continuity of our diabetic education Self-Management Support New tools to streamline documentation for diabetes education A more structured program with materials that are more current (Several respondents mentioned having very limited time to teach patients.) Community Need to work with the community to establish our own resources here Collaboration with another facility on how to develop an efficient and thorough inpatient diabetic education program Other General Comments for Specific Training or Resources All would be greatly appreciated and helpful. We have a well established OP program but nothing for inpatient. Unsure what is available and what reimbursement issues there are Training and Resource Preferences Preferred methods for receiving updated diabetes training and resource materials were: samples in print format (96%), web-based resources (93%), professional in-state conferences (89%), identification of trainings with CEUs (89%), identification of informal continuing education sources (89%), sharing strategies with colleagues via listserv (87%), resources available on CD- ROM (87%), group teleconferences with diabetes experts (78%), linkage with local experts, such as certified diabetes educators (78%), and listings of relevant national conferences (48%). Respondents reported varied familiarity with state diabetes control efforts and several other useful diabetes improvement resources as indicated below: Wisconsin Diabetes Prevention and Control Program 57% Wisconsin Essential Diabetes Mellitus Care Guidelines 65% National Diabetes Education Program 46% Chronic Are Model and components 22% Quality Improvement Model 35% 15

16 PART 2: CONCLUSIONS AND RECOMMENDATIONS Major inpatient diabetes care management needs that were identified through the critical access hospital assessments are reported as priorities below. Listed after each identified need are some suggested recommendations for hospital staff to consider that may help improve inpatient diabetes care. These recommendations were developed by the Critical Access Hospital Diabetes Project Workgroup and are reasonably consistent with those identified in the joint ACE/ADA consensus statement on inpatient diabetes and glycemic control (7). The challenge for critical access hospital staff will be to try to decide on improvements that are feasible to undertake given the competing demands for limited resources at the local level. Facilities are encouraged to assess their hospital environment and work to implement at least a few recommendations that may be pertinent to improve their inpatient diabetes services. During the critical access hospital assessment process, many respondents indicated that they were willing to share various useful resources and tools, such as protocols, policies, and documentation forms that they use to facilitate inpatient diabetes care. In order to help support an open forum for colleagues to share these resources as well as diabetes-related concerns with each other, the Wisconsin Office of Rural Health has developed a diabetes listserv. This listserv also provides the opportunity for hospital staff to share experiences regarding the lessons learned from various interventions and approaches, as well as a means to post up-to-date web-based, journal, and local continuing education opportunities to enhance diabetes-related skills. Staff members who provide services to inpatients with diabetes are encouraged contact the Wisconsin Office of Rural Health to sign up for this listserv. Priority Need #1: Improve staff development skills regarding diabetes care Many critical access hospital respondents reported that they re encountering more complex inpatient care needs due to shorter hospital stays and higher acuity levels. Despite the increased level of care needs, personnel indicated they have limited access to convenient, relevant, continuing education and training on current diabetes care management. Project Workgroup Recommendations Identify and promote convenient, free or low-cost, self-directed continuing education opportunities, such as web-based training, teleconferences, audio-conferences, CD-ROM, on-line libraries, and other distance learning technology, to enhance diabetes management skills and maximize staff resources; share identified opportunities on the diabetes listserv Identify and promote basic competency standards for staff that provide inpatient diabetes care Explore the capacity for in-house staff training, such as regular updates with a local diabetes expert or (e.g., certified diabetes educator, registered dietitian, pharmacist, etc.) 16

17 Priority Need #2: Enhance access to inpatient diabetes expertise Many critical access hospital respondents indicated that their facilities lacked access to diabetes experts, such as registered dietitians, certified diabetes educators, pharmacists, or specialty physicians, to consult with on diabetes inpatient management concerns. Project Workgroup Recommendations Explore opportunities to expand access to expert diabetes consultation and management updates through evolving technology channels, telemedicine, and/or academic detailing Consider increasing hours for inpatient diabetes specialty staff (e.g., registered dietitians, diabetes educators, pharmacists) Consider the feasibility of sharing a certified diabetes educator among the hospital s inpatient, outpatient, nursing home, and home care settings (or even with other hospitals or clinics) Priority Need #3: Standardize protocols and policies to guide inpatient diabetes care management Many critical access hospital respondents reported that their facilities lacked standardized guidelines to facilitate consistent diabetes care management across the continuum of care. Assessment data revealed disparate use of various inpatient diabetes-related protocols. Project Workgroup Recommendations Develop a systems approach to standardize diabetes care delivery through the development of hospital protocols (e.g., such as for the prevention and treatment of hypoglycemia, hyperglycemia treatment, insulin delivery, DKA treatment, bedside glucose monitoring, referral, discharge, etc.) Share existing samples of inpatient diabetes protocols though the diabetes listserv Adopt inpatient diabetes protocol recommendations currently under development by the Wisconsin Diabetes Advisory Group, once they become available Develop a method to regularly review existing protocols for safety and appropriateness Priority Need #4: Promote multidisciplinary steering teams to assess current processes and barriers to care and to help guide improvement interventions Personnel reported a lack of multidisciplinary teams and/or local champions in their facilities who could guide inpatient diabetes care management and lead improvement initiatives, such as the development and implementation of policies and protocols. Many respondents also reported a lack of consistent methods for the provision of inpatient diabetes education services, such as facilitation of referrals, assessment of patient knowledge and skills, regular review of education materials, and documentation. Assessment information also showed there were inconsistencies with discharge planning and limited staff awareness of barriers concerning referrals to outpatient education services and community resources. Project Workgroup Recommendations Utilize the diabetes listserv to facilitate the exchange of strategies and resources to improve inpatient diabetes care with colleagues Identify local champions who are interested in improving diabetes care to lead your facility s intervention efforts (such as the development and implementation of protocols, 17

18 provider education, quality improvement, etc.) and to help leverage necessary resources and support Explore development of a multidisciplinary team, or even a modified team, to guide inpatient chronic disease management, to explore local barriers to effective care, and to improve communication and coordination of care Establish a system to standardize diabetes education materials and for a regular review process to ensure accuracy and relevancy; ensure ready availability of designated materials to inpatient staff Explore use of a preadmission/admission questionnaire and a skills assessment process for patients with diabetes (even those admitted for another condition) to direct further inpatient and outpatient diabetes education needs Formalize a referral and discharge process to facilitate a smooth transition from hospital to outpatient care and to help assure appropriate follow-up and linkage to community diabetes education programs; include provision for follow-up needs for further screening for patients identified with hyperglycemia during hospitalization Develop a listing of community resources to help link patients and families to essential supportive services Explore opportunities to develop and expand community linkages to increase awareness about the growing epidemic of diabetes, risk factor reduction, and diabetes prevention strategies Priority Need #5: Promote systems that can evaluate diabetes-related data on an ongoing basis and guide quality improvement efforts Few respondents reported the availability of diabetes-related data for their facilities, making it difficult to discern the extent of the capacity of their data systems to generate either individuallevel or facility-wide reports. While it was suggested that respondents might need to consult with other hospital staff to complete some sections of the assessment tool, many don t know responses to the data questions were received. The short timeline for completion and return of the assessment tool may have been a limiting factor in obtaining data-related information. This may also have been a factor in the limited reporting for the section on barriers concerning referrals to community diabetes education services. Project Workgroup Recommendations Explore opportunities (e.g., through the diabetes listserv or meetings) to dialogue with other critical access hospital staff to share experiences with data management programs/systems Explore the capacity of existing data systems to collect, monitor, and evaluate inpatient diabetes-related outcomes Commit more resources to data system improvement and data management Explore the use of standardized documentation methods and forms to promote efficiency, timely access to critical clinical information to facilitate decision-making and plan of care revisions, and ease of data retrieval through chart abstraction in the absence of the capacity to track care through electronic data systems Identify persons with diabetes in the medical record at the time of admission to the hospital and also at the time of discharge (for those identified during their hospitalization) Expand existing satisfaction surveys to include for evaluation of diabetes care services 18

19 Promote collaboration with affiliated health systems, insurers, and other potential data partners to expand quality improvement capacity and opportunities for shared learning Promote the development of national, standardized inpatient measures to facilitate accurate collection and comparability Other Project Workgroup Recommendations The Critical Access Hospital Diabetes Project Workgroup encourages the WORH Flex Program Coordinator to continue to serve as a representative on the Wisconsin Diabetes Advisory Group (DAG), a network of the state s major diabetes organizations. This membership provides the means for potential access to collaborate with these organizations, as well as linkage with the Wisconsin Diabetes Prevention and Control Program (WDPCP). The WDPCP coordinates the DAG and many of its collaborative activities and has extensive knowledge about diabetes care and resources. For example, the DAG partners are currently collaborating on a project to develop recommendations for inpatient diabetes protocols. These recommendations are very relevant to the needs identified in the critical access hospital assessment and can be shared via the listserv once they become available. The project workgroup encourages the Wisconsin Office of Rural Health Flex Program Coordinator to share the results of this assessment report with the Wisconsin Diabetes Advisory Group. The project workgroup also recommends that the Wisconsin Office of Rural Health establish a link from its webpage to that of the Wisconsin Diabetes Prevention and Control Program to facilitate identification of relevant diabetes resources. 19

20 Section A: General Information PART 3: DETAILED ANALYSIS FINDINGS Questions 1, 2, and 3 asked for information on the date the survey was completed, the name of the participating hospital, contact information, and the length of time the contact has been employed at this hospital. Identifying information is not presented here due to confidentiality. Length of employment responses ranged from one month to 39 years. The average length of employment was years. 4. IS THERE A STAFF PERSON AT THIS HOSPITAL WHO HAS SPECIFICALLY BEEN IDENTIFIED TO COORDINATE THE CARE OF INPATIENTS WHO HAVE DIABETES? [E.G., CDE, RN, RD, HEALTH EDUCATOR, ETC.] 20 respondents selected yes (43%) 26 respondents selected no (57%) Yes 43.5% 56.5% If respondents answered yes to question 4 indicating there was a person specifically identified to coordinate the care of inpatients with diabetes, they were asked to also answer questions 4a, 4b, and 4c. 4A. COULD YOU PLEASE DESCRIBE WHAT THIS PERSON DOES TO COORDINATE INPATIENT DIABETES CARE AT YOUR HOSPITAL? Twenty individual responses to this question are included below. Inpatient education; referral for outpatient education Provide video tapes, handouts to staff along with supplies to teach injection; have also done inpatient teaching 20

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