Improving Diabetic Management in Long-term Care

J Clin Pathways. 2022;8(1):16-18. doi:10.25270/jcp.2022.02.4

Clinical pathways have the ability to improve all aspects of the Quadruple Aim especially when they target specific populations in specific care settings. Such is the case for the management of diabetes in long-term care (LTC). When developing these clinical pathways one can lay them out by first descripting the why, then the who/when, what, and how. 

Improving Diabetic Management With the Quadruple Aim

The Quadruple Aim can be improved through the patient experience via making better the quality of life (QoL) for diabetic patients. Population health for the LTC community through such issues as fall reduction. Costs through the impact of diabetic management on total cost of care, from primarily the adverse effects of negative outcomes. And staff burden from the impact of sliding scale insulin to management of adverse events. 

Patient Experience

With a focus on patient-centered care, diabetic management begins with an appreciation of each patients’ own individual care goals. This is critical as it dictates target outcomes as well as how those outcomes are met. Take, for example, a LTC resident with a limited life expectancy of less than one-year that is no longer interested in needles both in the form of monitoring and medication. Such a resident would be expected to have a higher target hemoglobin A_1c (HbA_1c) with less glucose monitoring and use of injections. This would be contrasted with a resident with a significant life expectancy along with desire to be aggressive in treatment and monitoring. For each resident, knowing their care goal and level of aggressive monitoring/treatment is essential to guiding their management.

Population Health

For the LTC population, a major goal of diabetic management is the reduction of traumatic falls. These falls are often the result of hypoglycemic events, so assuring an elimination of hypoglycemic events through appropriate HbA_1c targets and overall diabetic management is a focus of diabetic population health care. 

Costs

While diabetic medications can be costly, it is important to assess these costs in the context of both total cost of care as well as from the patient perspective. Since long-stay residents are typically dually eligible (Medicare/Medicaid) their out-of-pocket for Medicare Part D drugs is zero. Also, for the skilled nursing facility (SNF) during this long stay, the facility is not responsible for the cost of treatments as they are during the short-stay/subacute period. 

Of course, the most significant costs in diabetic management is the high cost associated with negative outcomes, both from adverse events and treatment failures. These occur in the form of hypoglycemic events causing traumatic falls. Long-term hyperglycemia also has a negative effect on peripheral vascular, renal function, and infections. While these represent the most significant of costs, there are also costs associated with staff time required for the care and treatment of diabetic patients in the form of glucose monitoring, medication administration, and adverse outcome care.

Staff Burden

The original Triple Aim was expanded to include an aim toward reducing staff/caregiver burnout. Realizing that the original is only achievable through supporting both formal and informal caregivers, reducing overly complex diabetic treatment regimens as well as reducing adverse outcomes can have a significant impact on caregivers. This is especially true in the era of COVID-19 where staff burn out is increasing from COVID-19 demands as well as looking for opportunities to reduce the spread of COVID-19 through reduction of unnecessary care touches. This reduction in unnecessary touches can come in the form of reducing the use of sliding scale insulin and unnecessary blood sugar checks. 

Who/When to Target for Care Improvement

While all LTC diabetic patients are in need of care, there are several types of patients to target for diabetics patients that require focused attention. These include those patients receiving sliding scale insulin, complex regimens, suffering or at risk for hypoglycemic events, and those with HbA_1c levels outside of their individualized target range. And while it does take some time and effort to improve these individual patients’ care, these efforts can be reduced through a facility diabetic management process. Establishing such a process is critical as without it the Quadruple Aim will suffer.

Sliding Scale Insulin

Many times diabetic patients are treated in the hospital with sliding scale insulin as a means to control their blood sugars, while being cared for an acute condition with high variability in oral intake and level of activities. These patients are admitted to the SNF on supplements security income (SSI) and continued this regimen. 

Complex Regimen

There are two groups receiving complex regimen. There are the patients in the short stay who will be transitioning home where a complex regiment managed by SNF nursing staff worked; however, once left to self-management it is highly likely that these same patients will be unable to manage these complex regimens.

The other group are those residents in long stay where these overly complex regimens are causing hardships for both the resident and staff.

Hypoglycemic Events

Patients with hypoglycemic events should be targeted as they present a real risk of suffering a traumatic fall. 

HbA_1c Levels Outside Range 

HbA_1c targets need to be individualized for each LTC resident based on their goals of care.

What Information is Available to Guide Care Improvement

The what is the opportunity to pull in the most recent clinical data available to best guide clinical pathways. For diabetes management this includes information available from the BEYOND trial.¹ The BEYOND trial evaluated the feasibility of either basal insulin plus glucagon-like peptide 1 receptor agonist or basal insulin plus sodium–glucose cotransporter 2 inhibitor to replace a full basal-bolus insulin (BBI) regimen in participants with type 2 diabetes and inadequate glycemic control. BEYOND provides evidence that it is possible and safe to switch from a BBI regimen to either a once-daily fixed-combo injection or once-daily gliflozin added to basal insulin, with similar glucose control, fewer insulin doses, fewer injections daily, and less hypoglycemia. This data is especially helpful in improving outcomes for the LTC target groups of those on SSI, complex regimens, suffering hypoglycemic events, and HbA_1c levels outside target ranges. 

How to Improve Diabetic Management

Improvement of diabetic management in LTC needs to occur on both the facility/system level as well as individual patient. On the facility/system side, each LTC facility needs a detailed diabetic management plan for patients. Beginning on admission where issues such as  sliding scale insulin are identified and addressed as well as specific patient goals of care. 

Taking Time to Improve the Process

The story goes that there is a lumberjack in the forest busily cutting down trees but finding it exhausting work. He is chopping and chopping but finds the process extremely time consuming with poor outcomes. When someone taps him on the shoulder and says why don’t you simply take some time to sharpen your ax so your work will be easier. He looks up and says I don’t have time for that.

This is often the case for diabetic management in LTC. Many times, staff and providers feels frustrated in managing SSI, yet they believe they don’t have the time to make needed adjustments to improve the process.

From an individual patient perspective, beyond individualizing care for each patient there is the opportunity through the monthly drug regimen review (DRR) for consultant pharmacist to make specific recommendations. Often these recommendations go unacted upon despite the US Centers for Medicare and Medicaid Services requirement for attending providers to comment on all DRRs. One way to overcome this barrier is with a collaborative agreement between the consultant pharmacist and attending. This can allow these DRR recommendations to be put into action.

Conclusion

In the end, diabetic management can be improved in LTC through taking the time to establish a clinical pathway addressing the diabetic management process for the facility as well as an individualized plan of care for each diabetic patient. This is needed to achieve all the Quadruple Aims—reduced caregiver burden, lower total cost of care, improved population health and, most importantly bettering the patient experience. This same process can be applied to other conditions in other specific clinical settings with similar positive clinical and financial outcomes. 

References

1. Giugliano D, Longo M, Caruso P, et al. Feasibility of simplification from a basal-bolus insulin regimen to a fixed-ratio formulation of basal insulin plus a GLP-1RA or to basal insulin plus an SGLT2 Inhibitor: BEYOND, a randomized, pragmatic trial. Diabetes Care. 2021;44(6):1353-1360. doi:10.2337/dc20-2623

Author Information

Author: Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Affiliation: EVERSANA™, Berkeley Heights, NJ

Disclosures: Dr Stefanacci has served as a Sanofi Scientific Education Program speaker as well as chief medical director for the managed markets agency of EVERSANA™.