This is an exciting time for providers caring for persons with diabetes. The first 5 months of this year, I had the opportunity to care for older adults with diabetes in a PACE (Program for All Inclusive Care for Elders) program where I was serving as the Interim Medical Director. Our participants may be homebound, fail to keep medical appointments, and may live with poor glycemic control and multiple complications of diabetes. In a brief period, I saw the benefits of comprehensive supportive healthcare using a team approach that parsed identified problems to members of our team with expertise in each area. As a provider, I was able to prescribe newer effective medications (some given subcutaneously weekly at our center) with less hypoglycemic risk than insulin or sulfonylureas. At team conferences we were able to simplify the care and help their families and caregivers provide supportive care that was beyond the capacity of the participant alone. When appropriate, we provided CGMs (Continuous Glucose Monitors) for about 2-4 weeks to better understand the effectiveness and safety of our medical interventions. In the brief time I was there, I saw safer and more effective care with hemoglobin A1c’s dropping from the 13-16 range into the 8-9 range. As that happened, I saw dramatic improvements in the participants’ cognition and quality of life.
Since that position ended, I’m back working part time in a SNF and have observed a more traditional approach to diabetes care, where we tend to continue the meds that a patient was taking in the home and/or hospital setting, including ill-advised regimens like sliding scale insulin. SNF attending clinicians may note complications, but tend to assume dental, vision, podiatry care, and poorly assessed glycemic control will be addressed better in the outpatient setting once they are discharged from our rehab program—an assumption that may not be accurate in the first place. If residents do not progress sufficiently in rehab to return to the community and become custodial residents, diabetic management still tends to continue to be more reactive than proactive.
AMDA: The Society for Post-Acute and Long-Term Care Medicine and other experts are challenging us to become more proactive in the care we provide for our residents with diabetes. I have reviewed the teaching slides AMDA has developed and found ideas for quality improvement projects that meet the necessary SMART criteria for QAPI projects. AMDA has updated their Diabetes Management CPG (Clinical Practice Guideline) and will be presenting an implementation Webinar on 8/26 as part of their summer monthly “Encore Series.” CALTCM will also provide an implementation presentation at our Annual Summit in Napa in late September. There is a small charge for these materials and teaching sessions, but the payoff could be huge and well worth the investment. See links below for these resources.
This is an exciting time in diabetes care with important care advances. Now is the time to gear up for constructive change that simplifies our care and improves our residents’ lives.
Resources
Diabetes Management Teaching Slides: https://paltc.org/products/diabetes-management-teaching-slides
Clinical Practice Guidelines: https://paltc.org/products/diabetes-management-cpg
AMDA Summer Encore Series 3 Topics – August is for DM implementation:
I always appreciate your insights! When I was still a practicing psychologist, I would frequently make home visits. This was an eye-opener as well as a heart-opener. Most of my patients had T2D, but were poorly educated regarding what they needed to do (other than get their A1C down before the next visit to their PCP) to monitor and maintain their blood-sugars. If that had been the only issue, a simple visit from home health might have solved the problem, but there were frequently additional factors. Having a team approach, sharing information, and truly coordinating care is actually a more sustainable model of care than our current "system". There is legislation currently being introduced to expand the PACE model to a full-on community PACE. I hope I live long enough to see it realized!