Give diabetic patients an attitude adjustment

QI project keeps diabetics out of hospital

Owners of a Chicago home care agency knew their normal way of serving clients would have to change once the agency became part of the Outcomes Assessment and Information Set (OASIS) project.

Suddenly the focus was on outcomes and the prospective payment system. As the agency collected information for OASIS, Mae Campbell, RN, part-owner of Campbell’s Personal Care Inc. in Chicago, could see that the diabetic patients were staying in home care too long.

"The agency was doing a lot of visiting," Campbell says. Patients were visited by nurses for six months to one year on average.

Not only that, but the patients were failing to improve because they wouldn’t comply with dietary and lifestyle changes, she adds. They often returned to the hospital during home care treatment or soon after being discharged from home care.

The agency, which has between 500 and 1000 visits each month, serves many poor and illiterate patients in the inner city of Chicago. The patients were poorly motivated to improve their own health, so Campbell knew her small agency needed to start a QI project that would tackle these issues.

The standard treatment for a new insulin-dependent patient was to have the nurse visit the patient each day to administer insulin. The daily visits would last for two weeks. Then as the patient became more comfortable with injecting his or her own insulin, the visits would cut down to one or two times per week, and these would last six months or longer, Campbell says.

That changed with the OASIS project: "Now with a new patient we start off daily for one week, cut down to three times a week, then two or one times for four weeks," Campbell explains.

Weekly visits now last between three and six months, which is about half as long as before.

Even better, the patients are being readmitted to the hospital less than they were before. Campbell has no hard data available for comparison, but she says that since the program began in January 1995, there hasn’t been a single case of a diabetic patient being readmitted to the hospital for problems relating to the disease within 45 days of discharge.

Previously, Campbell states, patients were constantly being readmitted for problems related to their diabetes.

Campbell’s Personal Care achieved these outcomes by attacking the problem at its roots: patients’ attitudes.

Old attitudes clung like a leech

The staff had to overcome the patients’ firmly entrenched expectations that they were entitled to being taken care of by the home care agency.

"The old system was the patients were dependent on someone else to take care them," Campbell says. "Now the focus is on the patient and caregivers to take over some of the care."

At first, patients did not understand why the nurses were placing limits on their services.

Patients constantly would tell nurses that they believed they should receive all their medication and home care services for free from Medicare and Medicaid. They viewed housekeeping services as a bonus of maid service for them and their families. "We told them that the housekeeper comes in to help the patient and not to take care of other family members," Campbell says.

Nurses had a hard time changing patients’ attitudes because some agencies in the area still provided such service, she explains.

The staff eventually succeeded with most patients, and here’s how they did it:

Nurses emphasized that times were changing.

Some patients would call Campbell to complain that they were missing out on services they deserved. And the agency lost a few patients. But Campbell says she didn’t mind that, because she didn’t want any patients who were unwilling to change their attitudes.

"We let the patients know they have to take some responsibility," Campbell says. "We let people know what they can and cannot do, and they have to stop manipulating one system against the other and face facts."

Slowly the nurses made progress in changing patients’ perceptions. They did so by talking with patients about the nation’s changing health care industry.

Nurses asked patients to watch the nightly news reports about how expensive the health care industry had become. And they showed them health care literature put out by the American Association of Retired Persons in Washington, DC, and other organizations.

The staff told patients that if the country was going to bring down the cost of health care and improve their personal health care, then the responsibility to lower costs is partly theirs, Campbell says.

"They began to realize that what they had been perceiving and what they were hearing from friends were not true," Campbell says.

Nurses focused on teaching them about injections.

Once a patient’s attitude changed, the nurses would work on educating him or her about how to best maintain the disease.

Many of the patients had the same feelings about insulin injections that they had about shots when they were children. Before the QI project, the nurses would teach patients how to give themselves injections. But the education often didn’t stick because the patients would stop giving themselves injections and would instead ingest insulin tablets, which aren’t as effective.

"They’d convince the doctor to give them oral medication, so they would end up with blindness, limb loss," Campbell says.

Campbell had the nurses redouble their efforts. This time they first told patients about how they would become sicker if they continued to take the tablets instead of the injections.

Then nurses answered patients’ fears about subcutaneous injections. They showed them how it is nothing more than a pinprick right under the skin, and they can learn to give themselves an injection that will not be painful.

"Once you pinch the skin a little it alleviates the pain," Campbell says.

Then nurses reassured patients that the needle would not leave scars and disfigure them.

"Once they know how to do it and do good skin care, they can take insulin for years and it won’t leave marks," she adds.

After these fears were alleviated, the nurses would show them how to give themselves the shots. After a few days of administering the insulin, the nurse would ask the patient to try it while the nurse assisted.

Then the nurses would make bargains with the patient: "I will do it this day, and you do it that day."

When the nurse would return on a day after the patient had injected him- or herself, sometimes the patient would have more confidence and would exclaim, "I was able to do it myself."

Nurses demonstrated how to prepare a healthy meal.

It was difficult changing patients’ attitudes, but it was even harder to help them make lifestyle changes. These called for some flexibility.

Many of the patients, for example, were accustomed to high-fat meals full of sugar and salt. Besides being diabetics, most had hypertension.

The agency worked at convincing patients that if they cheated on their diets it hurt no one but themselves. If they lost their eyesight or a limb, it was their loss and no one else’s.

It wouldn’t have worked to force them to completely change their grocery shopping and cooking habits, Campbell says. Plus, many of the patients were illiterate and couldn’t read food labels. But there were ways they could eat their usual foods and make them more healthy.

Nurses visited their homes and showed them how to cook the same canned beans in a healthier way. The nurses taught them to rinse canned foods and to refrain from adding salt when cooking them. Campbell herself went into homes and showed patients how to add lemon to foods or to sprinkle spices on them for flavoring.

Instead of salting a baked chicken, the patients were taught to use lemon or bell peppers for seasoning. Vegetables could be added to the dish.

If the patients questioned why they couldn’t eat much salt, the nurses would explain that their hypertension will cause them many health problems, including a diminished sex drive.

Nurses also showed patients how to do meal planning and how to cook without using grease.

"They learned to steam, boil, drain foods," she says. "It’s not saying that you can’t ever eat a piece of fried chicken again, but just don’t eat so much of it."

Both nurses and aides reinforced the education by sharing cooking tips. The staff also told the patients how the new diet would allow them to maintain their bodies so they wouldn’t feel so sluggish all the time.

"Say they like sweet pot pies. Instead of using sugar we used Equal, 2% milk, an egg, and we’d get rid of the pie crust and butter, which are all fat," Campbell explains.

Instead, the patients could use a nonfat oil spray and add vanilla to enhance the flavor.