Including Rehabilitation Professionals As Part Of A DFU Prevention Team

As an occupational therapist (OT), in my experience, a rehabilitation prescription including diabetes management can have better outcomes. Physical therapy, occupational therapy and speech-language pathology (for cognition/safety) could potentially contribute to a comprehensive preventive diabetic foot program. When the rehabilitation team, including nursing, focuses on patients with diabetes wearing proper shoes for their vulnerable feet everyone wins. Appropriate shoe gear may also take steps towards increased balance for fall prevention. The rehab team may also place referrals to providers for diabetic shoes, when appropriate.

Together, we can educate patients on performing daily blood sugar readings, and in our protocol, we encourage logging this data in a custom ring binder. This binder has tabs for various diabetic topics.  Each day on the calendar has a check-off box for blood glucose tests, checking the feet/legs, applying cream and performing exercise. There are spaces for the patient to record their blood glucose number and note hyperglycemic or hypoglycemic. Face symbols can indicate symptoms such as excess perspiration. A color-coded red/yellow/green column sheet may help those with low health literacy to choose appropriate foods. The exercise tab will have each patient’s home exercise program outlined in an accessible fashion. In all of the above, a “keep it simple” approach works best avoiding overwhelm and inspiring hope. We plan on implementing even more interventions like this in a group patient-driven payment model (PDPM) in our nursing facility. “Buy-in” happens when the patients learn from each other, especially if someone had a toe or foot amputated!

In our facility, we work to teach patients about choosing low glycemic foods with simple handouts and assisting with planning their daily menu. Then we follow up by cooking some easy meals and exploring new recipes according to their history of favorite dishes. Education on administering insulin and medications take place concurrently with OT and speech-language pathology (SLP) assessments treating the cognition and vision issues. Daily skin integrity and care by checking the legs and feet is paramount, as podiatrists are keenly aware. OT has marvelous adaptive equipment choices for lower body dressing and checking skin integrity. When a patient can’t get to their feet, OT can duct tape a hand mirror to a long wood dowel and/or explore alternatives on the internet. Similarly, a long shoe horn may assist in applying emollients to the feet correctly. When there is dementia, brain issues or low health literacy, a custom, personalized, colorful, large print wall sign may help the patient. It is amazing how we find this increases adherence to recommendations! When a patient is in a skilled nursing facility for at least two weeks a high degree of adherence is achievable! In this proposed scenario, the patient hears diabetes management information and reinforcement from every team member and actively implements these items daily.

In my experience, including the reasons above, the rehab team can be an integral part of an effective multidisciplinary diabetes management team. The American Occupational Therapy Association agrees, and elegantly presents the unique training and features of an OT professional that relate to these goals.¹ Podiatry’s involvement is clearly imperative, and I envision collaborative rehabilitation/podiatric screening clinics as a valuable tool in the skilled nursing and rehabilitation communities. Sadly, utilization of primary prevention of complications of diabetes is spotty in most health care systems. And over 39 years of working with seniors in a multitude of medical settings, implementation of secondary prevention may become delayed in patients with DFUs. Barshes looked at 1,000 repeated simulations of 100,000 hypothetical diabetes patients with no current or historical DFU, over a period of five years in one-month intervals. By applying costs of both primary and secondary preventive measures to all levels of risk-presenting patients (low to high), cost thresholds, at which at least 90 percent of simulations demonstrated savings.² As health care professionals, we know how much prevention matters. However, when considering valuable contributors to your preventive pathway for DFUs, remember to include rehabilitation professionals to round out the team and/or fill gaps that may exist in your health system or community.

Ms. Kean is an Occupational Therapist with 38 years experience in Oregon, and is President of Geriatric Rehab, Inc., a company that provides educational video classes to medical professionals, insurance companies and senior communities. This blog is adapted with permission from https://www.geriatricrehab.biz/category/diabetes/ .

References

1. Occupational therapy’s role in diabetes self-management. American Occupational Therapy Association. Available at: https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/Diabetes%20fact%20sheet.pdf// . Published 2011. Accessed July 19, 2021.

2. Barshes NR, Saedi S, Wrobel J, Kougias P, Kundakcioglu OE, Armstrong DG. A model to estimate cost-savings in diabetic foot ulcer prevention efforts. J Diabetes Complications. 2017;31(4):700-707.