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Case management takes many forms
The purpose of the University Diabetes Treatment Center at Parkland Health & Hospital System in Dallas is to encourage self-management — it helps patients take charge of their diabetes so they are in control rather than their disease being in control of them. Once patients are admitted to the program, they begin learning self-management skills such as blood glucose/urine ketone monitoring, record keeping, insulin preparation and administration, and meal planning.
Lori Allums, RN, diabetes clinical nurse specialist there, acts as the case manager in the unit for coordination of care and discharge. She also teaches them about the types of diabetes, the prevention and treatment of acute and chronic complications, exercise and sick-day management, and some pathophysiology.
"Without self-management, complications can take over their lives down the road," she says. "We stress that you often don’t feel sick when your sugars are high — 200 to 300 mg/dl. That’s the scary part about diabetes. The disease is easy for patients to ignore because they don’t think they’re having a problem. We let them know that, even if they don’t feel bad, their nerves and other parts of their bodies are being affected by high sugars." Parkland’s program provides patients with information on how to take care of themselves, but learning self-management doesn’t always come easy in the two to three days a patient spends in the center. Factors such as language, vision, educational level, and a person’s ability to interpret numbers can make the learning process difficult.
"Since our mission is to educate, if a patient can’t learn for one reason or another, he won’t benefit from our unit. We are a county hospital, so we get a lot of patients who are homeless and drug addicted," says Allums. "They forget to take their meds. We see the same people come in over and over, and they are challenging to work with because often they don’t take an interest in their health."
Parkland is the only inpatient diabetes unit recognized by the Alexandria, VA-based American Diabetes Association (ADA) in the Dallas/Fort Worth area. The 10-year-old center is directed by Allums, and patients are cared for by a dedicated dietitian, 10 nurses, two nursing assistants, a medical director, three rotating attending physicians, and interns.
She says they also see repeat admissions for people who were sick and thought they shouldn’t take insulin. "We teach them it’s true that if they take insulin and don’t eat, they can get low blood sugar. But of course the insulin has to be adjusted to their needs."
Since Parkland’s unit has only 11 beds, they can’t take every diabetic admitted to the hospital. With the help of the hospital case manager, a diabetes fellow assesses every diabetic patient who is admitted and sees if that patient would benefit from being on the specialized unit. A typical unit admission is a person with an unhealing abscess who has never been diagnosed with diabetes. Without specialized care, infection can set in, and an amputation could result.
Zeroing in on the walkie-talkies’
"Over the years, patients were admitted to this unit who were walkie-talkie’ — they were feeling fine except that they needed to be put on insulin," says Allums. "Now, with managed care, people are typically started on insulin in an outpatient setting."
James Rosenzweig, MD, the director of disease management at the Joslin Diabetes Center/Joslin Clinic in Boston, says that it used to be routine for diabetic patients to be admitted and treated for several days in the hospital, but now insurance companies mandate outpatient care. The trend is to get patients out as fast as possible. Even so, he says, "it’s probably better for elderly diabetic patients or those with multiple chronic illnesses or compliance issues to be kept for a few days. You don’t want their problem incompletely treated, then have it exacerbate. I’ve seen house officers incompletely treat ketoacidosis — they bring the blood sugars down to normal, but neglect to clear the acidosis and ketones — and their patients relapse very quickly."
Allums says her Parkland unit gets the patients who have other comorbidities but need insulin as well. They get some of the sicker patients, such as those with diabetic ketoacidosis. "In another facility, those patients would be transferred to the ICU. Our nurses are trained to manage them with an insulin-glucose infusion protocol. They adjust their insulin requirements depending on their blood sugar." If a patient needs to be on a heart monitor or ventilator as well, he goes to the ICU.
For 15 years, Diabetes Treatment Centers of America (DTCA), a subsidiary of American Healthcorp in Nashville, TN, has provided management services to hospitals nationwide and presently provides a comprehensive plan for inpatient diabetic management to 72 customer hospitals in 29 states.
Hospitals pay considerable fees for the services of DTCA, and those fees "are confidential," says Robert Stone, MBA, executive vice president of DTCA, "but utilizing our services increases a hospital’s market share by creating a reputation for the hospital as a source of experts in diabetes services." Also, he explains, taking care of these patients efficiently reduces the cost of treating them, and facilities find that dollars are produced that pay the company’s fee.
For the hospitals who contract, DTCA gets involved in the management of every patient with diabetes, beginning from the moment the company is notified by admitting.
"We work with case managers throughout the inpatient stay," says Stone. "We support and enable them and the whole nursing staff to be aware of the unique needs of the diabetic population," he says. The consultants work with all departments of the hospital on systems modification so that, for example, patients aren’t sent to X-ray without first getting a meal. They also work one-on-one with the attending physicians to make sure the needs of patients with unique metabolic management problems are not overlooked.
Perioperative management of the diabetic
Diabetics often have multiple complications that can prolong their surgical hospitalization. They don’t do as well as nondiabetic patients following surgery because it takes longer for them to heal.
"Perioperative management is extremely important in terms of outcomes," says Stone. "It’s a critical population to work with. Diabetic patients tend to stay in the hospital 30% to 40% longer than patients without diabetes with the same admitting diagnoses. Healing rates are slower and infection rates are higher. Mortality rates are closely related to metabolic management."
Rosenzweig says cardiologists in particular tend to ignore blood glucose control during the time patients come in for CABG procedures. "It’s usually when they are getting ready to discharge patients that cardiologists discover that their patients’ levels are out of control and that there are a variety of other complications as well. Then they call in the endocrinologist." It would be better if the endocrinologist managed the patient from the beginning, he says. If good glycemic control is achieved early, problems can be dealt with more easily. When it is not, infections are prolonged and more difficult to treat, and sugar levels take longer to come under control. "The issue is that diabetes is a multisystem disease," explains Rosenzweig. "It involves many problems — cardiovascular, renal, neurological — and all tend to magnify the overall problems."
Susan Burke, RN, BSN, diabetes program manager for Blue Cross Blue Shield of the Rochester, NY, area says she routinely helps hospital case managers with their initial contacts with diabetic patients by giving them information they may not have. "For example," says Burke, "my records show if a patient has ever had an HbA1c or an eye exam. Those are the kinds of things we can advise case managers to follow up on."
Blue Cross’s Diabetes Disease Management Program, begun in 1997, identifies members with diabetes using claims data and hospital admissions information. Burke and her colleagues have access to the names that are downloaded monthly to the diabetes registry — they are people who are admitted for any related or unrelated problem. She can look at the information on a patient and see how he is being followed. "Is he getting connected to care? If he has heart disease, has a cholesterol check been done? We go through an algorithm," Burke says, "and a red flag goes up for someone who should be assigned to a follow-up phone call after discharge, or if someone should be on a list for a mailing that reminds him that he hasn’t had an eye exam in two years, for example."
She says the admission of a patient with uncontrolled diabetes is a window of opportunity that shouldn’t be missed. While he is in the hospital, you can get an understanding of what happened to the patient that landed him there and how it could have been prevented. She says that with proper education, many admissions for uncontrolled diabetes could be avoided.
"One of the key issues we’re looking at now," says Burke, "is making sure the diabetic’s primary care physician or endocrinologist knows his patient is at an ED when the patient presents there. When a person with diabetes comes into the ED, there’s often no communication with his doctor. The doctor doesn’t know the patient has come in, so he can’t do appropriate follow-up on discharge to make sure that whatever happened to the patient doesn’t happen again. That doctor needs to know his patient stopped taking insulin for 10 days, for example, or whatever else pushed him over the edge."
Make yourself indispensable
Joan Totka, RN, MSN, certified diabetes educator (CDE) at Children’s Hospital of Wisconsin Diabetes Center in Milwaukee, says case management is key across the continuum of diabetes management. "That’s where people have to look when they address diabetes. The clinical path is an important piece, but case management is very important too." She explains that pediatric diabetic ketoacidosis is different from adult diabetic ketoacidosis. "Kids can die from mismanagement if adult guidelines are followed. Case management includes the outpatient care of these children."
Totka says that often a diabetes clinic has to demonstrate its value to hospital administration. "Diabetes programs are labor-intensive and are not money-makers. They are more of a public service."
Maria Barnwell, president of E2M Health Services in Dallas, agrees: "The diabetic patient is expensive. They spend about 1.7 days longer in the hospital than the nondiabetic patient."
Totka says that clinics tend to lose money, but you can capture revenue for your clinic from the lab or pharmacy. "The lab is the golden child of any hospital. They have no costs compared to the money coming in. You can point out, Maybe my clinic doesn’t make money, but look at the revenue generated in the lab from the patients who come from my clinic.’"
Another way to demonstrate value to your administration is to point out how the clinic is affecting the community and how its influence stretches beyond hospital walls, says Totka. "Get them to look at the global perspective. They’ll see they can’t do without you. We do outreach programs where we distribute educational materials in schools and elsewhere. Not only do we impact the community, but diabetes management is seen as one of the facility’s best programs, not because it makes money but because we are indispensable."
Peggy Gardner, PhD, director of medical education and executive director of research at Via Christi Health System in Wichita, KS, was part of a team that developed a clinical algorithm for its diabetes project called Freedom With Diabetes.
"Our diabetes case managers originally came out of an area in the hospital called diabetes care," she says, "an old-style, pre-managed care inpatient education program where patients would come for five days and go through the program. Those case managers had a focus on diabetes and are valuable to the project."
A project that lowers risk
Designed as an outpatient project, the Free-dom With Diabetes team developed tools for use in physician offices, including a resource manual, chart stickers, and reminder sheets. Offices also received inexpensive glucometers and simple disposable devices for testing pedal neuropathy.
The primary care physicians in those offices fax referrals to the project where telephone operators use scripted materials to contact patients and answer questions. A care coordinator performs a risk assessment and enrolls appropriate patients into an education program. She also provides links between patients and specialist providers and sometimes intervenes to meet with patients and their doctors.
Gardner says the project was begun three to four years ago with the assumption that good care coordination and good communication could reduce risk in the diabetic population. "Our ultimate goal," she says, "was to get HbA1cs down. Nurses, CDEs, and physicians — both endocrinologists and family doctors — worked together to develop an algorithm of care for Types 1, 2, and gestational diabetics." There are now 200 enrolled in the program. The project was not fully implemented until last February, and outcomes are not yet available, but it is thought that the project will cost $500,000.
[Contact Lori Allums at (214) 590-8054, James Rosenzweig at (617) 732-2415, Susan Burke at (716) 238-4631, Joan Totka at (361) 902-4196, Maria Barnwell at (972) 687-9052, and Peggy Gardner at (316) 291-4900.]