Transcript Diabetes Care Program of Nova Scotia (DCPNS)

Diabetes Care Program of Nova Scotia
Diabetes Guidelines for Elderly Residents in
Long-Term Care (LTC) Facilities
Update and Next Steps
Overview
• Provincial Programs (role)
• Diabetes in Nova Scotia
• Diabetes Guidelines for Elderly Residents in Long-Term
Care (LTC) Facilities
– How we got to where we are
– Review of key messages
• Findings from study project
• Next steps
– Moving forward—how?
– Evaluation considerations
Mandate of Provincial Programs
• Advise the Health System through the
development/recommendation of standards/guidelines.
• Recommend service delivery models.
• Educate, communicate, and recommend implementation
strategies in support of service providers/organizations.
• Monitor uptake of approved standards and systems
outcomes.
DCPNS Works….
 Across the continuum—all populations, all providers, all settings
 In partnership
 To inform change
Policy Work:
• Insulin Pumps
• SMBG
• Referral Pathways
DCPNS Survey
Process
Foot
Resources
PA & Ex
Tool Kit
Partnerships/Research:
• Diabetes Assistance Program
• Physical Activity & Exercise
• PreDiabetes—lifestyle program
• Dal: - Transition Research
- Chronic Disease Mgmt
• Psychosocial Support
• HTN FP Network • SMBG
• Academic Detailing
Insulin
Dose
Adjustment
:
 Basic
 Specialty
NDSS
• Report
Guidelines:
 HTN
 Lipids
 PreDM
 Triage
 Pregnancy
 Pediatrics
 LTC
Forms:
 Referral
 Adult
 Pregnancy
 Pediatrics
(mailed selfassessment)
DCPNS Registry:
• Interface • Reports
User Support
PHAC-funded:
• Survival Analysis
Project (severity)
• Repository (NSDR)
Partnerships Across
Provincial Programs
• Hypertension
• Integrated CDM
• Surveillance (Epi)
• Guidelines Inventory
• Cultural Competence
Lens (guidelines)
Knowledge
transfer/exc
hange:
 Newsletter
 Workshops
 Annotated
 Website
DHA Projects:
• A1C Persistently >9%
• MD/NP Patient List
• Wait times (Triage Guidelines)
• DC Grants (3-4/year)
May 2010
DIABETES IN NOVA SCOTIA
What we know….
Crude Diabetes Prevalence for the Population
Aged 20+ in Nova Scotia and the DHAs –
2008/09
Source: Nova Scotia Diabetes Statistics Report 2011 (DCPNS)
Source: Nova Scotia Diabetes Statistics Report 2011 (DCPNS)
Trend in Diabetes Prevalence for the Population Aged
20+ in Nova Scotia by Age Group – 2004/05 to 2008/09
Source: Nova Scotia Diabetes Statistics Report 2011 (DCPNS)
Clients with Diabetes--% of Initial
LTC Placements/Fiscal Year
Source: NS DHW, SEAscape Database, June 2011
DCPNS Diabetes Guidelines for Elderly
Residents in Long-Term Care (LTC) Facilities
Guidelines Development/Dissemination
• 2003
Needs Assessment
• 2004
Established Diabetes in LTC Committee
• 2004 to 2007
Development of Diabetes Guidelines (specific)/
Pocket Reference
» Hypoglycemia Treatment &Targets for Glycemic Control
• 2007
Pilot Project—3 facilities (1 rural and 2 urban)
•
•
•
•
DCPNS Advisory Council Approval
Release—Dissemination: TeleHealth, direct mailing…
Project (Ivey School of Health Innovation and Leadership)
Phase 2 of the guidelines in development (monitoring)
2009
2010 (Apr)
2010/11
2011
• Next steps/evaluation
Purpose
• To standardize DM management of the frail elderly
residing in LTC facilities through the development of
reasonable glycemic targets and appropriate treatment of
hypoglycemia.
• Considering:
– Frailty/comorbidities
– Life expectance
– Safety (risk of over/under treatment—hypoglycemia)
– Quality of life
Targets for Glycemic Control
• The goals of managing diabetes in elderly residents
admitted to a LTC facility are different than for people in
younger age groups.
KEY MESSAGE
• Avoid the acute complications of poor glycemic control
including hypoglycemia and prolonged, severe
hyperglycemia.
Targets for Glycemic Control
Hypoglycemia
Rationale:
• Hypoglycemia in the elderly person with DM can be serious
and may be underestimated.
– Fewer symptoms of hypoglycemia or  awareness of
hypoglycemia.
– Poor balance and  risk of falls.
– More severe and prolonged hypoglycemia can precipitate a CV
event.
• Dementia may limit ability to communicate symptoms.
• Multiple medications and kidney or liver impairment, may
lead to changes in breakdown of medications (risk of hypo)
HYPOGLYCEMIA TREATMENT (cont)
ICP Final Presentation
Team 24: Y. Ma, J. Szeto, J. Younan, K.
Yuen
Diabetes Care Program of Nova
Scotia (DCPNS) Guideline
Adoption Project
Richard Ivey Centre for
Health Innovation and
Leadership. U of Western On
Diabetes Care Program of Nova Scotia (DCPNS)
Mission Statement
“To improve, through leadership and
partnerships, the health of Nova Scotians
living with, affected by, or at risk of
developing diabetes.”
ICP Project Objectives
Having distributed the ‘Diabetes Guidelines for Elderly Residents in
Long-Term Care (LTC) Facilities’ across Nova Scotia, DCPNS required
consultants to achieve two objectives:
1
Assess adoption of the
guidelines in Nova Scotia and
identify facilitators and
barriers to adoption/uptake.
2
Determine how to measure
adoption accurately, and the
most efficient means to
increase adoption to 40% of
LTC facilities.
Province-Wide Survey Breakdown (Questions 4 - 15)
Question 4: How familiar are you with the Guidelines….
Administration Staff
Medical Staff
Never heard of them
Never heard of them
2
3
Only heard of them
2
9
Have read them, but
do not use them for
residents with
diabetes
Have read them and
do use them for
residents with
diabetes (where
applicable)
Only heard of them
9
5
Have read them, but
do not use them for
residents with
diabetes
Have read them and
do use them for
residents with
diabetes (where
applicable)
Administration staff: 100% had heard of the guidelines
Medical staff: 69% use the guidelines suggesting facilities are effectively engaging their
staff in implementation; however, 15% of medical staff have not heard of the guidelines.
Knowledge transfer from administration staff to medical staff can be further improved
Province-Wide Survey Breakdown (Questions 4 - 15)
Question 5: Have there been any formal communications created
by administrators/managers regarding the guidelines…?
Administration StaffNo. Not aware of any
Medical Staff
No. Not aware of
any upcoming
communications/se
ssions
upcoming
communications/sessio
ns
4
6
6
7
Yes. Have been told
about the
guidelines through
communications,
and sessions have
been held to
further outline
their use/educate
staff.
6
Yes. Have been told
about the guidelines
through
communications, but
no sessions held to
further outline their use
Yes. Have been told
about the guidelines
through
communications, and
sessions have been held
to further outline their
use/educate staff.
Administrative staff: only 25% cited formal communication sessions to educate staff
Medical staff: 54% indicated a current lack of initial and ongoing communication to
reinforce knowledge and awareness of the guidelines in LTC facilities.
Province-Wide Survey Breakdown (Questions 4 - 15)
Question 6: Who is responsible for establishing Policies..?
Medical Staff
Administration Staff
Physicians
7
13
10
Physicians
10
Nurses
Dieticians
9
7
Administr
ators
Nurses
Dieticians
10
13
Administr
ators
Medical and Administration Staff collectively suggest that implementation responsibility is not
the strict responsibility of administrators. While information was only sent to administrators,
there must be a concerted effort to directly communicate with other groups in facilities.
Province-Wide Survey Breakdown (Questions 4 - 15)
Question 14: What form has implementation taken…?
Medical Staff
5
6
Administration Staff
4
No implementation
activities apparent
9
No implementation
activities apparent
New policies
New policies
4
5
Readily available
pocket references
for staff
New standing
orders for persons
with diabetes
9
4
Readily available
pocket references for
staff
New standing orders
for persons with
diabetes
No form of implementation was dominantly used, showing that facilities implement in
ways that match their needs (not necessarily the best or most thorough way). Many
staff reported changes in policy or standing orders demonstrating clear use of
guidelines. In four situations, respondents reported all three forms of implementation.
Three Key Project Findings
KEY FINDING 1
KEY FINDING
2
KEY FINDING
3
Implementation
Urgency should be
Reinforced at LTC
Facility Level
Complex
Stakeholder
Characteristics &
Networks
Lack of
Benchmarking &
Feedback Process
Primary and secondary research indicate that three critical issues prevent
DCPNS from increasing adoption in LTC facilities beyond current levels.
So…
• We have made progress…but…We have more work to do…
• Next steps:
• Refine the survey instrument
• Re-survey all sites (January 2012)
• Support implementation/uptake—sharing, focused work, local
champions
• Finalize, distribute, and promote uptake of new guidelines
(A1C and bed side monitoring)
• Evaluate (how do we know we have been successful?)
– What should we look for and how do we do this?
In closing…
• Can we count on you??
• Questions….general discussion
Thank you …..
Measuring Guideline Effectiveness
Major Indices of Guidelines Effectiveness (staff and administrators)
80%
80%
73%
70%
60%
30%
20%
#2
Reduced insulin
doses/initiation
#3
Patient reported
quality of life
70%
53%
50%
40%
#1
Number and frequency
of calls to the attending
physician.
40%
30%
10%
0%
The above three indices can guide research on how to measure the
guidelines’ impact on improving health of elderly residents.