Diabetes Continuum of Care: Transitioning to Prevent Readmission. Beth Pfeffer RN, BSN, CDE Director, Diabetes Services The Nebraska Medical Center

Transcription

1 Diabetes Continuum of Care: Transitioning to Prevent Readmission Beth Pfeffer RN, BSN, CDE Director, Diabetes Services The Nebraska Medical Center Objectives Identify Best Practice guidelines and recommendations for improving inpatient diabetes care Describe the role of the Diabetes Case Manager and Diabetes Resource Nurse as an integral piece of the model Discuss education methods utilized to increase level of diabetes knowledge for healthcare team Discuss processes and protocols for reducing length of stay and readmission rates Review measures of clinical and financial impact of the program 2 1

2 Hyperglycemia: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital 12% 26% 62% n=2,020 * Hyperglycemia: Fasting BG 126mg/dL or random BG 200 mg/dl x 2 Umpierrez G., et al. J Clin Endocrinol Metab. 2002;87: Patients with Co morbid Diabetes Have Longer Lengths of Stay than when Diabetes is Not a Complicating Factor Average hospital length of stay (ALOS) when diabetes is a secondary diagnosis. American Diabetes Association. Economic Costs of Diabetes in the U.S. in Diabetes Care 2008;31:

3 Readmission Rates Higher for Patients with Diabetes Among 48,612 patients with congestive heart failure from 259 hospitals, 42% had diabetes All cause rehospitalization was significantly greater for patients with diabetes than for patients without diabetes (31.5% vs 28.2%; P =.006) 32% 31% 30% 29% 28% 27% 26% Rehospitalization Rates 28.2% 31.5% No Diabetes Diabetes Greenberg BH, et al. Am Heart J. 2007;154:277.e1-8. ACE/ADA Major Recommendations for Optimal Glycemic Management in Hospitalized Patients Identify elevated blood glucose in all hospitalized patients Establish a multidisciplinary team approach to diabetes management in all hospitals Implement structured protocols for aggressive control of blood glucose in ICUs and other hospital settings Create educational programs for all hospital personnel caring for people with diabetes Plan for a smooth transition to outpatient care with appropriate diabetes management 3

4 The Beginning Findings from Glycemic Control 2005 Benchmarking Project (UHC) 69% of non ICU blood glucose levels were greater than 180mg/dL. 18% of blood glucose levels in all areas (ICU and non ICU) were greater than 200mg/dL. Measures of Success 1. % organizational compliance of blood glucose between mg/dl: organization / unit and provider 2. Incidence of Hypoglycemia 3. ALOS diabetes vs. non diabetes patients 4. Diabetes documented on admission 5. A1c on admission if not available within last 60 days 6. Daily Glucose Report Patient and Unit Specific 7. Rate of Glucose Extremes (% >300mg/dl and < 40mg/dl) 8. Readmission Rate for patients with diabetes 4

5 90% 85% Organizational Glucose Trend Performance mg/dl compared to mg/dl for blood glucose control New Org Threshold 75% Year average 82% 80% 75% Year average 76% 70% Performance Performance Perc cent Incidence of Hypo oglycemia 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Organizational Hypoglycemia. Events less than 70mg/dl. 55% decrease in incidence of hypoglycemia from 2008 to % 4.0% 3.6% 3.2% 2.9% Need updated graph with FY 12 ytd 1.8% Year 08 Year 09 Year 10 Year 11 Year 12 Trended Year to Date 5

6 Diabetes and Non Diabetes LOS by Fiscal Year Diabetes ALOS Non Diabetes ALOS Savings to organization over 8 yrs = $2,690,142 EDUCATION! EDUCATION! EDUCATION! A Challenge Medical Staff Nursing Pharmacy Laboratory Dietary/Nutrition Must be creative, innovative and presented in multi formats 6

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8 Insulin Type and Action Time Tool Available on all units Modified to pocket size for nursing and medical staff Utilized as marker in Utilized as marker in patient chart for most recent insulin order 8

9 Achieved Joint Commission Certification for Advanced Inpatient Diabetes Care November 10,

10 WHAT NEXT? Challenge issued by CNO to develop a plan to focus on the continuum of care for patients t with diabetes/hyperglycemia Goals 1. To improve quality of glycemic care 2. Focus on transition of care 3. Reduce risk of readmission 19 Traditional Inpatient Diabetes Education Model Goal to provide DSMT to patients and families to accommodate safe transition to home or post acute facility Survival Skill Curriculum 3 CDEs dedicated to inpatient daily RN, RD Team but function = as CDE Physician or Nurse generated consult 20 10

11 Inpatient Diabetes Education Consults FY2010 FY2011 FY Inpatient Diabetes Program Team Structures Glucose Management Team Diabetes Services Director Medical Director Diabetes Clinical Quality Coordinator Diabetes Nurse Case Managers Diabetes Resource Nurses Newton C, et al. Endocr Pract. 2006;12(suppl 3):

12 Roles and Responsibilities of Diabetes Case Managers Assigned to med/surg units with highest population of patients with diabetes/hyperglycemia Case manage defined high risk diabetes population for discharge planningand and transition of care Adequate supplies Self management skills Post hospital follow up (Provider for diabetes management, Education, Home Health) Use daily interactions and collaborations with medical and nursing team to improve glycemic management through ongoing education and increasing awareness of hyperglycemia Uncover opportunities in glycemic management and encourage medical team to make treatment changes in collaboration with physician Partner with Inpatient Case Managers, Social Work, Pharmacy, to meet needs of pt population Diabetes/Hyperglycemia High Risk Patients Self pay patient with diabetes diagnosis New diagnosis type 1 or 2 DM, transplant related diabetes, CFrelated DM, steroid induced DM New to insulin DKA admission Hypoglycemia admission Readmission due to diabetes hypoglycemia or hyperglycemia 12

13 Diabetes Resource Nurse Staff Nurses on units who receive comprehensive inpatient glycemic management education and act as resource/advocate for championing Best Practice bedside practices Role Pay it Forward Educate other staff Disseminate information to Unit Based Council of education or initiatives Participate in review of policies, procedures, tools, education for inpatient diabetes care Participate in ongoing education updates Work in collaboration with Diabetes Case Manager in providing diabetes specific patient education Staff RN Role in Diabetes Management Perform learning needs assessment, health literacy, setting and prioritization of goals Evaluate and update diabetes self management skills assessment Partner with Diabetes Case Manager and Diabetes Resource Nurse in coordinating diabetes needs Provide patient education for diabetes self management skills to include Medication (insulin administration and oral medication Blood glucose monitoring Hypoglycemia recognition and treatment Hypoglycemia recognition and treatment Utilize Diabetes self Management patient education record for documentation of education (on intranet) Utilize Diabetes specific patient handouts (on intranet ) 13

14 Interdisciplinary Collaboration Pharmacy : Diabetes Discharge Kit Social Work: Coordination of Home Health Referral Inpatient Case Managers: Coordination of discharge needs/ Prior Authorization for supplies Role of Medical Call Center Questions on Post Hospital F/U Call: 1. Have you had any blood sugars less than 70mg/dl? Have you had blood sugars greater than 250mg/dl for hours? If yes to either refer to Diabetes Case Manager 2. Do you feel confident using you meter and taking your insulin? If No refer to Diabetes Case Manager 3. Do you have a follow up appointment with the provider that will address your diabetes treatment? Do you have transportation to the appointment? If no refer to Diabetes Case Manager 14

15 Certified Diabetes Educator/Case Manager Glycemic Expertise Training Pyramid Diabetes Resource Nurse 6 hours Training Annual Diabetes Update 4 hour Symposium Annual Diabetes Competency All New Hires RN Staff Training 2 hour Class 4 6 months after hire Diabetes Resource Nurse Education Interactive vs. didactic Geared at glycemic management at the bedside From Admission to Discharge 5 8 nurses from each unit and Clinical Educator 6 hours initial; 2 hour follow up 3 months post; annual 4 hour update 15

16 Focus on Agenda Insulin terminology: Basal, Bolus, correction; action times Timing of BG monitoring, meal, insulin Special situations: NPO, steriods, TPN, enteral feeds Carbohydrate Counting Hypoglycemia Case Studies from actual error reports Unit Level Outcome Measures % BG in mg/dl Rate of hypoglycemia (<70mg/dl) Extremes Rate ( > 300mg/dl or < 40mg/dl Readmission Rate Insulin Errors/Glucose Management Errors 16

17 INSULIN / GLUCOSE MANAGEMENT ERRORS 42 patients on insulin on CPCU audited 3-5 days each in March 2012 for errors in insulin/glucose management Total Omission Errors (insulin or glucose monitoring) on 42 pts audited over 3 day period on CPCU Omission meal time insulin Omission background insulin Omission correction insulin Omission BG monitoring n= 58 total errors Errors were pre-defined for administration and omission of insulin or glucose testing >60 from poc to correction 27 > 60 to scheduled time > 60 meal to insulin Pre meal and correction given at separate times n=52 total errors Summary of Insulin/Glucose Management Errors Total Insulin/Omission/Administration Errors = 110 Error/ Pt = Insulin Omission Errors BG Monitoring Omission Errors Insulin Administration errors 17

18 Hospital Readmissions 15% 14% TNMC Readmission Rate 14.1% 13.9% 13.6% 13.6% FY12YTD Organizational Readmissions Readmissions Discharges without readmission 13% 86.4% FY2010 FY2011 FYTD 2012 % of NMC readmissions with diagnosis of diabetes *2012 not complete Total % 35.0% 30.0% 25.0% % of readmissions with diagnosis of diabetes 35.6% 37.9% 30.3% 69.7% 30.3% FY12YTD Diabetes Readmissions Non Diabetes Readmissions 20.0% FY 2010 FY 2011 FYTD 2012 Total 2258 Prevalence of patients discharged from TNMC with diagnosis of diabetes? % Discharge pts with Diabetes 23.3% 22.9% FY2010 FY2011 FYTD 2012 FY12YTD % of Patients discharged by diabetes and non diabetes diagnosis 77.1% 22.9% Diabetes Discharge pts. Non Diabetes Discharge pts. % of diabetes patients readmitted within 30 days of discharge at TNMC % of Diabetes Readmissions from DiabetesDischarges Discharges within30 days 23.0% 18.0% FY2010 FY2011 FYTD , 82% FY12 YTD Diabetes Readmission Rate 684, 18% Diabetes Readmissions Total

19 Project RED (Re engineered Discharge) applied to diabetes specialty population Components: 1. Medication reconciliation 2. Reconcile dc plan with National Guidelines 3. Follow up appointments 4. Outstanding tests 5. Post discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Dc summary to PCP 11. Telephone Reinforcement "You won't realize the distance you've walked until you take a look around and realize how far you've been. " Unknown 19

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