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Boost all outcomes by improving diabetes care
Check use of meters, medication, and diet
Over 20 million people in the United States are diagnosed with diabetes about 7% of the country's population, according to the National Diabetes Information Clearinghouse, a service of the National Institutes of Health. More than 20% of people age 60 or older have diabetes.1
The prevalence of diabetes, especially in older people, means that most, if not all, home health agencies have patients who are diabetic. The challenge is recognizing the impact diabetes has on overall care, even when the primary diagnosis is not diabetes, according to experts interviewed by Hospital Home Health.
"Our patients may have diabetes but most of the time the primary diagnosis for home health admission is not diabetes," admits Janet Morrison, RD, CDE, registered dietician and diabetes educator for HealthEast Home Care in St. Paul, MN. "They can have any one of or a combination of diagnoses but we need to make sure we know about the diabetes," she says. Of all other conditions the patient may have in addition to the reason for home care, diabetes has the greatest impact on the outcome of most primary diagnoses, she points out.
"If a patient is not managing their diabetes, wounds won't heal as well and treatment for other conditions won't be as effective," says Morrison. "We use a multidisciplinary approach to diabetes care so that all of our staff members are educated about diabetes and know how to educate the patient." Staff education courses cover an explanation of what diabetes is, the importance of managing blood sugar levels, and how to use different meters. "We also have a clinical pathway that all employees, including social workers and aides as well as nurses, can use to determine what steps need to be taken if a patient is not managing their diabetes well," she says.
"We make sure that we identify the diabetes during the initial assessment," says Morrison. Patient education regarding diabetes is an ongoing effort, she says. "At the initial assessment, staff members make sure the patient understands the importance of measuring blood sugar levels at regular intervals and that they know what their acceptable levels are and how to properly use their meter," she says. "There are so many different meters available and some are easier to use than others, so we often suggest other options if the patient has trouble with their meter."
Setting codes on the meters presents problems for many patients, points out Joy Pape, RN, CDE, a diabetes nurse educator and president of EnJOY Life Health Consulting in New York City. "Elderly patients often forget this step, which affects the accuracy of their readings," she explains. "There are new meters on the market that don't require codes so it is much easier for most patients." Other meters use larger displays to make the numbers easier to read or require less of a blood sample than older meters, she adds.
Watching the patient check themselves helps nurses identify reasons that testing is not done regularly and gives them a chance to suggest new products to the patient or to ask for a consultation with a diabetes educator to further evaluate the patient's technique, suggests Morrison.
Sometimes the lancet is the reason that patients don't check blood sugar levels regularly, points out Morrison. "Patients will save lancets to reuse to save money; as lancets get dull, they hurt more and patients will stop testing themselves," she says.
Because financial resources are an issue for many elderly patients, Morrison and the social workers at her agency often find themselves counseling patients on Medicare reimbursement for diabetes supplies as well as medication. "There are many patients that don't understand that supplies are covered," she says. "I have spoken with many pharmacists to set up accounts for my patients' diabetes supplies so that they can be reimbursed."
Not only do patients not realize that supplies and meters may be covered by Medicare, but many don't realize that a number of local pharmacies will deliver to the home, points out Pape. Patients may be ordering from another source because they deliver to the home but the advantage of using a local pharmacy is the fact that it can be the same pharmacy that handles all of the patient's medications, she adds. This simplifies the patient's record keeping and ensures that the pharmacist has a complete picture of the patient's medication use.
Check patient's knowledge
After making sure that the patient knows how to check blood sugar levels, nurses will check the patient's knowledge about their medications, says Morrison. "We ask what types of medication they take, how much they take and when, and what the potential side effects of the medication are," she says. "We also make sure they know the signs of hypoglycemia and what to do if they develop it.
"We know that there is a lot of information to remember, so we have a cheat sheet for both the nurse and the patient," admits Morrison. Having a quick reference tool to review ensures that the same information is covered with every patient, she adds.
Another important part of assessing a diabetic patient's home is making sure that they are eating regularly and correctly, says Morrison. "We ask if they can eat without difficulty and then we check to see that there is food in the house," she says.
When talking with patients about eating properly with diabetics, be aware that there is no "diabetic diet," points out Pape. "The best diet is a healthy diet that has decreased amounts of sugars," she says. If you talk about a specific diet that must be followed, patients may feel overwhelmed, she adds. "Just focus on eating healthy," she suggests.
Keeping the entire process simple is the key to compliance for most home health patients, says Morrison. "We teach nurses to check the meter's memory to double check information in case patient's don't remember everything. We also ask patients to keep a logbook, we pre-fill syringes, and we call upon an occupational therapist if the patient has difficulty with any of the tasks," she says.
If you make sure that patients understand why you are emphasizing diabetes care even if your primary reason for home care is wound care, you can increase compliance, says Morrison. She explains, "We explain that if they learn to better manage their diabetes, they can maintain their independence even longer."
1. National Diabetes Information Clearinghouse. National Diabetes Statistics 2005. www.diabetes.niddk.nih.gov/dm/pubs/statistics/#7.
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