Transcript Diabetes in the Elderly - Quality Improvement Organizations

Transition of Care
in patients with diabetes
Medha Munshi, MD
Joslin Diabetes Center
Beth Israel Deaconess Medical Center
Harvard Medical School
Case Vignettes
• 89 yrs old pt
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admitted with bilat. PE
on glipizide 5 mg bid at the time of admission
Prolonged and complicated hospital course
Required endocrine consult for difficult to control
blood glucose
– Discharged to rehab on 3 different scales needed
to control BS during the acute illness
– Now discharged from rehab to home on the same
regimen – returns to the clinic with wide
excursions of glucose
Case Vignettes
• 78 yrs old patient, caregiver for husband with
dementia, needed various strategies to control BG in
the clinic – simplified regimen was started
• Recently was asked by her cardiologist to go back to
basal bolus regimen due to high BS
• Admitted to the hospital for 14 falls in a month in
middle of the night
• Hypoglycemia ruled out during hospitalization and
ALL work up for syncope – negative
• Found by family to have multiple types of insulin
collected over months – patient was taking short
acting insulin 50 u at bedtime
Transition of care
Set of action designed to ensure the
coordination and continuity of health care
between different locations or different levels of
care at the same location
Acute care hospital
Rehab
Home
Primary / subspecialty care offices
Prevalence
2001 Harris poll by the Robert Wood
Johnson Foundation
-hospital discharge (>65 yrs)
- 23% to another institutions
- 11.6% with home care
19% transferred back from SNF to
hospital within 30 days
42% transferred within 24 months
-older adults with 1 chronic condition see 8
different MDs/year
Consequences of Fragmented care
• Inappropriate or conflicting care
recommendations
• Medication errors
• Patients/caregiver distress
• Re-hospitalizations
• Higher cost of care
Barriers to Effective Care
Transitional Care for Persons with Complex Care Needs
• The delivery system
• The clinician
• The patient
Coleman EA: J Am Geriatr Soc 51:549-555, 2003
The Delivery System Level
• Each institution has a distinct independent
delivery system (complicated by HIPAA)
• Lack of formal communication system
• Lack of financial incentive promoting
transition of care and accountability in fee-forservice Medicare.
• Different financial and contractual
relationships with pharma companies
• Lack fo quality indicators for transition of care
The Clinician Level
• Different physicians at different locations
• Productivity pressure on PCP – patients are
not followed across the care levels
• Hospitalization occurs at different locations
• Care manager and social workers operate
independently from primary team –
sometimes adds to the confusion
The Patient Level
• Little advocacy or outcry unless family
member is confronted with emergency
• Patient or caregivers are not prepared
to optimize care they will receive at the
next setting
Diabetes-Specific Challenges
• BG and insulin need change during acute
hospitalization
• BG and insulin need do not return to baseline at the
time of discharge
• Interaction between illness, anorexia, delirium post
hospitalization
• Discomfort felt by medical providers in changing
diabetes regimen
Diabetes-specific Complications
Post-hospitalization
• Hypoglycemia
if insulin dose is not lowered when acute illness
resolves, inadequate meals or weight loss
• Hyperglycemia
if inadequate insulin for persisting illness
• Stress for patient and caregivers
if discharged on new regimen/sliding scales
Ideal Discharge check-list for elderly
patients
society of hospital medicine’s hospital quality
and patient safety committee
Data
Elements
d/c
Summary
Patient
Instructions
HPI
Key findings
diagnosis
15 elements in total
Communication
Our Challenge
• To develop a better system to improve the handoff
esp. for patients with diabetes
• To provide access to a diabetes educator for
patient/caregiver for help after hospitalization (
pharmacy clinic is not adequate)
• To teach providers “transitional diabetes care”
• To develop care plan that is generalizable to all
communities
Diabetes regimen
At the time of
hospitalization
At the time of hospital
discharge
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Oral meds
Fixed dose insulin
Sliding scale regimen
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Oral meds
Fixed dose insulin
Sliding scale regimen
Reasons for change in
regimen from
previous
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Hyperglycemia due to
acute illness
Hypoglycemia due to low
oral intake
Fluctuating blood glucose
Oral
agent
contraindicated
Formulary issues
Anticipated change in
diabetes treatment
as patient recover
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At the time rehabilitation
discharge
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Oral meds
Fixed dose insulin
Sliding scale regimen





Hyperglycemia due to
acute illness
Hypoglycemia due to low
oral intake
Fluctuating blood glucose
Oral
agent
contraindicated
Formulary issues
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At the time of PCP visit
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Oral meds
Fixed dose insulin
Sliding scale regimen
Discontinue sliding as
tolerated
Discontinue insulin as
tolerated
Restart oral medications
as tolerated
Increase dose of insulin
as tolerated
Increase dose of oral
meds as tolerated
Discontinue sliding as
tolerated
Discontinue insulin as
tolerated
Restart oral medications
as tolerated
Increase dose of insulin
as tolerated
Increase dose of oral
meds as tolerated
Shared Experiences
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Hospital
Long term Care
Visiting nurses
Others?