Diabetes management is a complex process, requiring collaboration between clients and healthcare professionals. When those clients face significant obstacles in their lives, disease management becomes even more challenging.
A recently Adult Day Health Council (ADHC) Research Collaborative Diabetes Management Study, for example, focused on intensive interdisciplinary care led by nurse case managers made a difference in the lives of clients from 10 Adult Day Health Care Centers in New York City, upstate New York and Buffalo.
The centers serve primarily low income individuals with low health literacy and significantly restricted access to healthcare. The year-long study of 104 clients focused on the ABCs of diabetes management: A1C blood tests that identified blood glucose control, blood pressure control and cholesterol management.
"These are complex clients with multiple comorbidities. Similar cohorts of Medicare recipients who have five or more chronic illnesses experience as many 10 hospitalizations per year. [But] clients who attend the ADHC medical model have a much lower rate of hospitalization, despite a large percent also being afflicted with cognitive impairment or depression," explained Kathleen Falk, MSC, FNP, assistant professor at New York City College of Technology and chairperson of the ADHC study.
"It's important to identify how we can best use our nursing resources to help them stay in the community with support," Falk emphasized. "To control their A1C levels is a very significant accomplishment."
Easy as A-B-C
A structured care plan established the foundation for individualized diabetes management.
"While a nurse could easily become sidetracked by a hypertensive crisis that requires immediate intervention, for example, the ABCs of the care plan cues the nurse to look at the whole picture after the crisis is resolved," Falk said.
"People don't generally die of diabetes - they die from cardiovascular events. The care plan affirms the value of nursing care coordination in bringing together the diabetes team with a conference call."
Falk emphasized the importance of identifying barriers to treatment, rather than labeling clients as noncompliant.
"We have an interdisciplinary team for a reason, and a client's barriers to care can go unaddressed if the nurse doesn't make appropriate referrals," she said. "We were able to make headway by providing the nurses with education about identifying and managing depression, helping them understand that depression presents differently in the elderly, or that culture plays a role in how depression is expressed.
"Once we suspect depression, we further assess with symptom rating scales and make referrals to team disciplines such as social workers, psychologists, and psychiatrists."
The nursing case management approach has paid off handsomely. At each 3-month assessment, at least 60 percent of the clients demonstrated a statistically-significant decrease in A1C levels, and only 25 needed additional improvements. Data analysis demonstrated the effectiveness for the group as a whole.
Lory Dahlhauser, RN, CDE, a diabetes case manager at Kaiser Permanente's Stockton, CA medical offices, described the three-level population management model that her health maintenance organization has adopted for members with diabetes.
"Level 1 members are newly-diagnosed and attend classes while their primary doctor manages their diabetes," she said. "Level 2 patients have high A1c levels (above 8.5 percent) and receive telephonic assistance from RN or RD care managers for 6 months to a year to lower their A1c levels, blood pressure and cholesterol.
"All members with type 1 diabetes, members in renal failure and on dialysis, pregnant women, children with diabetes, and members on insulin pumps from our office are referred to me for case management."
When she receives a new referral, Dahlhauser calls the member directly to set up an initial appointment.
"I establish right away that we're going to work together to keep them safe and their disease under good control," she said. "I personalize the approach to target an A1c at a certain level, without incidents of hypoglycemia.
"The rule of thumb is 7 percent, but members who are older, have complications or experience significant hypoglycemia, may be encouraged to keep their A1c target closer to 8 percent."
Dahlhauser makes good use of the Kaiser Permanente website and the Internet for two-way communication with members.
"I have a lot of patients who email me, and that works well since I'm on the computer constantly," she said. "Once I'm on their provider list, they can send me messages and ask questions.
"A member may send me blood glucose results, for example, and I can review them and make an immediate change in insulin dosage. Insulin pump companies also sponsor a web-based computer program that allows me to use the member's password, review blood glucose trends and then email instructions."
Telephonic Case Management
Jody Pankow, BSN, RN, diabetes case manager at Physicians Plus Insurance Corporation, Madison, WI, recently transitioned to telephonic case management from her previous role as a diabetes educator in an ambulatory care center.
"I've been reviewing the files on members who received diabetes case management over the past year, and found some real successes," she said. "A lot of members started out with an A1C greater than 8.5 percent, 9 percent or even 10 percent but are now down in the 7 percent range."
Seasoned diabetes case managers understand the importance of identifying the knowledge level, learning readiness and self-efficacy beliefs that drive different individuals who have diabetes.
"The first group is made up on people who need a little extra motivation from someone who isn't their physician or health care provider," Pankow said. "They need someone to say, 'You can do this' and then they will take the bull by the horns, institute healthy lifestyle changes, improve their blood glucose levels and sustain their goal A1c over time."
The second group needs more consistent follow-up from their case managers.
"These are the members who start at 8 percent, go up to 9 or 10, drop down again and see-saw back and forth," Pankow said. "They do well with constant reminders, reinforcement and someone to hold them accountable. As soon as you say, 'OK, you're doing good! Let's touch base again in a month,' they go off track."
The third group does best in a collaborative relationship with the diabetes case manager.
"These members tell me, 'I know what to do, I just need to do it!'" Pankow said. "I work with them to identify issues and barriers to effective glucose control. Together, we explore telephonically and come up with strategies that work for the individual."
Staff members at Physicians Plus are in the process of obtaining accreditation for the diabetes case management program from the National Committee for Quality Assurance, NCQA. "We track HEDIS data about patient outcomes, including the A1C values," Pankow said.
Working with students in K-8, Bratt and her colleagues demonstrated that telemedicine visits between the school nurse, the student and the diabetes team made a big difference. The children had lower A1c levels than peers who didn't participate in the program, and reported significant improvements in their quality of life.
Kathleen Bratt, PNP, CDE, a nurse practitioner with the Joslin Diabetes Center at Upstate Medical University, Syracuse, NY, co-authored a study about the effectiveness of school-centered telemedicine for children with type 1 diabetes.
"The program had worked well in geriatric patients at home, so why not do it with a younger population through the schools?" Bratt noted. "We wanted to increase the knowledge base among school personnel, while improving diabetes management knowledge and skills in the children. In addition to meeting those goals, we made school staff feel like a bigger part of the overall diabetes management picture."
Bratt and her colleagues were able to correct some common misconceptions in the study, "School-Centered Telemedicine for Children with type 1 Diabetes Mellitus," published in the September 2009 issue of The Journal of Pediatrics.
"We heard many times that all diabetes is the same: 'My grandmother had diabetes, so I know what to do for students,'" she said. "We lovingly named some nurses and teachers 'the food police' because they removed items from the students' lunch boxes or wouldn't let them participate in classroom parties. We reduced the fear factor by discussing 'What If?' scenarios with those adults, and sharing effective strategies."
Completed in 2009, the research project launched a program that today involves students K-12, he telemedicine program resonated with students.
"The younger ones loved seeing themselves on the screen and interacting with me," said Bratt. "The older ones would ask specific questions about managing blood glucose before and after sports practice, for example."
Sandy Keefe is a frequent contributor to ADVANCE.