Part I: How Hospital CMs Impact CareM

Detect early, refer early: Good maxims for good diabetes case management

Hospital case managers are key to effective continuum care

Most successful diabetes programs rely on hospital case managers to coordinate comprehensive care for patients, especially for those who have severe disease or who are at high risk for complications. In some programs, a care coordinator performs risk assessments and enrolls patients in education programs. She works closely with patients in making necessary lifestyle changes and furnishes essential links with providers. In other programs, case managers make initial assessments, determine education and counseling, and give patients reminders for screenings.

What all diabetes programs seem to have in common are effective diabetes registries and suitable education programs, and what these both rely on is input and referral from hospital case managers.

Cathy Reardon, certified diabetes educator (CDE) at Winchester (MA) Hospital, depends upon her hospital’s case managers for many things, but near the top of the list is identification of diabetes patients who may be slipping through the system unrecognized. (See article on Winchester’s Casefinder program, p. 204.) Even if the glucose test administered upon admission shows normal readings, she says, it could merely mean a diabetic’s glucose is under control. Or an error may be made on a chart.

"It’s up to case managers as well as nursing staff to notice signs," she says. "Some symptoms of high sugar are excessive thirst, frequent urination, weight loss, and blurred vision. A signal can be as routine as when a patient complains to her case manager, I can never get the nurses to keep my water pitcher filled.’"

Maria Barnwell, president of E2M Health Services in Dallas, agrees: "Clinicians aren’t always automatically aware of a diabetic’s condition once he’s admitted. The admissions panel will catch an acute situation, but that’s just a snapshot. In the same way that an EKG won’t catch heart disease, the initial chemistry panel won’t catch diabetes." And, she says, only about 1% of diabetics’ inpatient admissions list diabetes as a principal diagnosis.

Barnwell says the case manager is a problem-solver. "When we go into a health system, we evaluate a hospital’s process of diabetes care. When we see room for improvement, we re-engineer their system. To do that, one of the first things we do is look at what they are doing in case management."

Reardon also works with Winchester’s case managers when the time for discharge draws near and patients need diabetes education. "Teaching inpatients is not usually productive," she says, "because they have too much else going on." Case managers have to make sure diabetic patients are connected at discharge with appropriate resources, says Susan Burke, RN, BSN, diabetes program manager for Blue Cross Blue Shield of the Rochester (NY) area. "Getting them connected with home care at discharge is important. Even if a patient doesn’t meet homebound criteria, there are times when it’s still a good investment to plug in home care services so a nurse can evaluate what’s going on that impacted that admission — the patient’s eating habits, for example, or his process of medication." She strongly recommends that the newly diagnosed patient receive home care follow-up as soon as possible after the disease has been identified. "Those newly diagnosed patients are overwhelmed with information," Burke says.

Burke says case managers can also ensure that in-house staff are educated on appropriate coverage for their surgical patients on insulin. "It would be rare for any admission not to be somehow impacted by a patient’s diabetes," says Burke. "Whatever brought the patient in — uncontrolled hypertension, problems with heart disease, chest pain, chronic ulcers — those conditions are closely tied to their diabetes management and poor glucose control. Even for the patient who is admitted for a condition unrelated to diabetes — trauma as a result of a car accident, for example — if the diabetes isn’t appropriately managed, healing is slowed due to erratic sugar levels."

She says when someone comes in for an ambulatory surgical procedure, for example, if house staff haven’t communicated with the patient’s doctor about diabetes management, they may write orders that take the patient off normal meds. If they put him on sliding scale insulin, they may not think to provide coverage for when he eats. "That scenario is particularly common for Type 1 patients," says Burke. "Then when, for example, the patient comes up with a blood sugar of 400 mg/dl, staff will say it’s uncontrolled diabetes, and they end up chasing their tails."

Reardon adds that inpatients’ glucose levels are generally 70 to 80 points higher than if they were at home — about 220 to 230 mg/dl as opposed to <140 to 160 mg/dl at home. The reason: Inpatients are in what she calls a sterile environment — they are fed the same amounts every day at the same time — which is quite different from how they eat at home. "Some eat very little while they’re in the hospital because the food is so different from what they’re used to, and their activity level is almost zero."

Even if someone is admitted with a stroke — probably related to diabetes, because they go hand in hand — Burke says it’s surprising, but house staff often don’t make the connection. And sometimes a patient who’s had a stroke and is hemiplegic as a result is discharged without instructions on how to compensate for his new disability in order to administer his insulin. "There are lots of places where plugging in a diabetes staff educator makes sense," she says.

The most important function the case manager has, according to James Rosenzweig, MD, director of disease management at the Joslin Diabetes Center/Joslin Clinic in Boston, is to coordinate diabetes education to ensure the patient is able to self-manage following discharge.

"We find that having a Joslin case manager double as a diabetes educator is a helpful tool," Rosenzweig says. "For example, if a patient has out-of-control diabetes because her blood glucose meter is malfunctioning or because she has not been taught how to adjust insulin doses appropriately, or if a patient has a new insulin dosage as a result of being in the hospital, she has to be educated anew so she knows exactly what she is supposed to be doing. The case manager should make sure that patient gets her education and has her insulin supply, and should see if a visiting nurse should come in to check glucose levels and adjust insulin doses." He points out that elderly diabetics especially need support services at home immediately after discharge, and it is the case managers at Joslin who coordinate that.

Rosenzweig gives as an example an elderly patient with poorly controlled diabetes. The patient may be confused or demented and stops taking her insulin. She develops high blood glucose and is admitted to the emergency department in a coma. She is put on IV insulin. Theoretically, that patient can be brought under control quickly, but if the patient can’t manage by herself because her cognitive skills are weak, she needs support. She may be able to self-administer her insulin, but she may not be able to handle testing and recording her blood sugar levels. Someone has to assess how well she does on her own and what kind of support she needs and is getting, such as coordinating visits to the eye doctor after discharge. That someone is the case manager, says Rosenzweig. "She can be involved in all those things."

Another example is a patient with poorly controlled diabetes who comes into the hospital with a foot infection due to nerve damage and peripheral vascular disease. He sees a vascular surgeon who does bypass surgery to restore circulation to the foot, or who may amputate. That patient needs ongoing services after discharge. His diabetes has to be brought under control or else the foot or amputation site won’t heal well. An endocrinologist may start the patient on a new regimen, and the patient needs education for that. "It is the case manager who coordinates those services so everything can be done expeditiously," says Rosenzweig.

Diabetic patients with conditions seemingly unrelated to diabetes need special management by the case manager as well. Her role in the case of the patient with a head injury, for example, is to follow that case through surgery. The patient’s diabetes needs to be controlled on a regular basis. If the patient is not eating, his insulin has to be adjusted. Sometimes an endocrinologist must be ordered to follow blood sugars, and the case manager has to expedite all the processes that are going on so last-minute problems don’t come up.

For more information, contact:

Cathy Reardon, certified diabetes educator, Winchester (MA) Hospital. Telephone: (781) 396-6437.

Maria Barnwell, president, E2M Health Services, Dallas. Telephone: (972) 687-9052.

Susan Burke, RN, BSN, diabetes program manager, Blue Cross Blue Shield, Rochester, NY. Telephone: (716) 238-4631.

James Rosenzweig, MD, director, disease management, Joslin Diabetes Center/Joslin Clinic, Boston. Telephone: (617) 732-2415.