Clinical Practice Action

by Timothy Gieseke, MD, CMD

Last summer, CALTCM formed the Clinical Practice committee under the able leadership of Dr. David Berman. We are clinicians very much aware of the difficulties our facility teams have upgrading care processes as new knowledge impacts the care we should be providing. With so many of our patients having diabetes as a key factor in their health, we have decided to mine the literature and think strategically with you, about how we might help our teams bring about incremental, sustainable, & measurable improvement in our diabetes care (QAPI). We realize our committee needs a greater representation from the work force we serve. If you are willing to review literature and bring your ideas to our monthly conference calls, we would welcome your participation.  We particularly need volunteers who are:  DON/ADON, Administrator, MDS Care Coordinator, NP/PA, Line RN /APRN, and consulting pharmacist.

As our first resource, we are developing a Facility Diabetes Assessment Checklist for use on post-acute care admissions.  This tool needs further modifications and then testing prior to recommending it for your use.  If your facility might be interested in testing it and giving us constructive feedback, please let us know.

As one of the developers of this tool, I must admit to a potential misuse of the tool.  Last week, I admitted a patient for post-acute rehabilitation who needed to complete IV antiviral therapy for a complicated viral meningoencephalitis in the setting of premorbid PTSD, fire related homelessness, class 3 obesity, and recently diagnosed poorly controlled DM with 10+ A1C.  On the basis of my comprehensive diabetic assessment, I proposed a comprehensive, but complicated set of interventions that would be covered by her insurance that would likely bring her to safe glycemic control, improve her obesity, and reduced cardiovascular risk.  I thought I had her buy-in even though she maintained during this assessment that she wasn’t a diabetic, had always refused immunizations, and was confident that all she needed to do was adopt a healthy lifestyle.

Unfortunately, she declined blood tests the next day, became more upset by the implementation of my care plan for her, and left AMA.  In retrospect, I needed to respect her denial of the severity of her problems as well as her confidence that she could control her problems with only a lifestyle approach.  I could have honored this approach, allowed for an orderly discharge from the facility, and trusted her PCP to review my recommendations and work with the patient in the future to develop an effective and acceptable care plan.

This case reminds me that what we do is complex and requires good listening skills and the ability to adopt tools and tasks to specific patients.  This work requires a team approach with optimal communication among our facility providers, our patients, and their community care team.

Please consider joining us on this new and important committee and also consider having your facility become a potential testing site, contact us at:  Together, we can improve the quality of healthcare in our communities.