EXECUTIVE SUMMARY

A telehealth program has case managers who follow a diabetes insulin adjustment protocol to better manage patients’ disease.

  • Nurse case managers were trained before they could use the protocol.
  • The protocol showed positive health improvement results.
  • Providers responded positively to the program.

Case management can be combined with treatment-specific protocols to quickly react to patients’ medical problems, resulting in better chronic disease maintenance, administrators of a telehealth program found.

A diabetes insulin adjustment protocol, used with a virtual case management program, helps reduce average blood sugar levels among at-risk diabetic patients. RN case managers were trained to use the protocol, which resulted in a reduction of average baseline A1c from 9.646 to an average of 7.685 A1c post-protocol use among about 150 patients, says Nancy Brown, MSN, ARNP, ANP-BC, advanced registered nurse practitioner at Mann-Grandstaff VA Medical Center in Spokane, WA.

“With diabetic patients we can manage them, and even adjust their insulin, over the phone,” says Freta L. Leddige, BSN, RN, nurse manager for home telehealth at Mann-Grandstaff VA Medical Center.

Before developing the protocol, the VA medical center had difficulty improving multi-complex patients’ diabetes, Brown says.

Previously, insulin adjustments could take weeks or months because physicians might wait until they saw the patient in their offices to make changes.

“I’m a provider, and before I started working with home telehealth nurses, I’d be in clinic, busy seeing patients — and then in the middle of the day the blood sugar numbers would pop up with a summary,” Brown explains. “I’d say, ‘I’ll look at it when I see the patient next month rather than break out of my clinic day and give a nurse an order to adjust the patient’s insulin.’”

Brown researched insulin adjustment strategies in the literature and attended a number of diabetes conferences, learning as much as she could. Evidence pointed to patients being able to self-adjust their basal insulin safely with instructions by nurses, who follow a standard order. In other words, a telehealth model could work.

The key is to create a protocol order that will be pre-approved by a medical review board and used by well-trained nurses to adjust treatment, Brown says. (See related story on the protocol’s use with technology in this issue.)

“So I worked with home telehealth nurses on an order they could use to adjust their patients’ insulin levels over the phone,” she explains. “We did an improvement project to see if this helped improve their A1c goal.”

They found that before the insulin adjustment protocol it took an average of eight to nine months to get patients’ blood sugar levels down to the desired level, but after using the protocol it took two to three months for improvement.

“We thought this was really exciting, so nurses started having more and more interest in managing their patients’ diabetes,” Brown says.

The following is how the protocol program works:

  • Develop a protocol. The diabetes insulin adjustment protocol gives nurses a clear recipe for when to adjust insulin levels, Brown says. (See template table in this issue.)

There are fields for the patient’s diet, exercise, medication compliance, rotating injection sites, and symptoms of hypoglycemia or hyperglycemia in the medical center’s insulin adjustment note template.

There are also fields for listing the current insulin dose and the last adjusted dose, including basal, prandial, average dose of prandial insulin at each meal, and total daily dose of insulin.

Other fields include average blood glucose for the past three days, recent blood glucose transmissions, the blood glucose chart, and a listing of whether blood glucose was not at individual glycemic goal.

Finally, the protocol’s insulin adjustment note template lists these four steps:

  1. Patient is instructed on changing the basal insulin dose and prandial insulin dose.
  2. Nurse reviews individual glycemic goal, signs/symptoms of hypo/hyperglycemia, treatment, and prevention of low blood sugars, including the 15-15 rule of hypoglycemia, diet/meal planning, and exercise as tolerated.
  3. Patient agrees with and verbalizes understanding of above plan and offers no questions or concerns.
  4. Continue home telehealth monitoring and insulin adjustment as needed.
  • Obtain approval from a medical review board. A medical review board first had to approve the protocol, says Barbara Carrara, MSN, RN, home telehealth case manager at Mann-Grandstaff VA Medical Center.

“A lot of doctors are hesitant to allow nurses to adjust medication, especially insulin, so that’s a big barrier,” Carrara notes. “That wasn’t just a barrier here, but also throughout the VHA system.”

With support from a Mann-Grandstaff nurse executive, Nancy Benton, PhD, RN, CNS, they overcame that barrier: “She would go to these high-level meetings and say, ‘My nurses can do this,’ and she’d present the protocol to them, convincing them that it was something that would be good for us,” Carrara says.

  • Provide proper training for nurses. “In order to make the protocol safe and effective, nurses utilizing it must have advanced education in diabetes,” Carrara says. “They don’t need to be certified diabetes educators, but they must have enough education to develop a solid understanding of diabetes, diabetes medications, and how these are affected by exercise, diet, illness, etc.”

Each case manager in the program received more than 20 hours of didactic education before the protocol was launched. Also, Brown provided nurse case managers with one-on-one mentoring, Carrara says.

The VHA facility created competencies through online training and mentoring, along with an annual test nurses must pass, Brown says.

Obtain physician buy-in. Physicians select patients who would benefit from the protocol and write an order for it. Obtaining physician buy-in was a challenge, but the pilot project’s results helped to build trust, Carrara says.

“One of the outcomes that our study supported was that there were no serious episodes of hypoglycemia during the study,” she adds.

In one case, a new provider was skeptical of approving the protocol, and she planned to pull her diabetic patients out of the home telehealth program and manage them herself, Carrara recalls.

“Thanks in good part to Freta’s education and support, she decided to give it a try, and now she refers all the diabetics she has a hard time controlling,” Carrara says. “We’ve developed such a good relationship with our providers.”

  • Ensure nurses follow stated rules. “When nurses are going to be utilizing a protocol that involves medication adjustment, they need to check with their state board of nursing, wherever they happen to be licensed, to make sure the state board says it’s okay to follow a protocol under your license,” Carrara says.