Challenges in Effective Discharge Planning for Hospitalized Patients With Diabetes

3. Effective Discharge Planning forContinuity of Care A1C on admission for all diabetic patients, as well as patients experiencing hyperglycemia prior to discharge Timely Referral to Inpatient Diabetes Educator if applicable Post Hospital Plan of Care discussed with Patients during Hospital stay � Nursing to reinforce Reconciliation of medications - If new to insulin, regime discussed with patient prior to discharge. Insulin Instruction Sheet given to patient to take home DME supplies � meter, syringes, lancet, needles etc. Referral for OP diabetes Self management If appropriate Follow-up care with PCP within 15-30 days, or if new to insulin within 7-14 days

4. Implications of Pre-AdmissionFactors for Discharge Planning Physical/ Self Care limitations � Blindness, Stroke, Amputation Socioeconomic Factors - Insurance Coverage, Family Support Access to follow-up Care � No PCP Learning barriers � Language, Cognitive, Dexterity, Competence related to diabetes self management Degree of control prior to admission and severity of hyperglycemia

5. Discharge Planning Challenges Pressures to discharge patient early Shorter hospital stays Competing priorities Lack of primary care physician Nursing workload Lack of diabetes specialist educator Weekend discharges

6. A1C is Helpful in DeterminingPost Discharge Treatment In those without previously diagnosed diabetes and an A1C level of: 6.5% or higher: Indicates the incidence of diabetes and referal to Inpatient Diabetes Educator is essential to begin self-management education prior to discharge 5.7 � 6.4%: Indicates a category of increased risk for diabetes. Lifestyle interventions that promotes weight loss and increased activity should be addressed prior to discharge Differentation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (FBG, 2H OGTT) once metabolically stable using established criteria

7. Patients Newly Diagnosed withDiabetes During Hospitalization A diabetes education plan should be developed for each patient prior to hospital discharge that address the following: Understanding related to the diagnosis of diabetes SMBG and explanation of home blood glucose goals Definition,recognition, treatment, and prevention of hyperglycemia and hypoglycemia Identification of healthcare provider who will provide diabetes care after discharge Information on consistent eating patterns When and how to take medication including proper disposal of needles and syringes Sick day management

10. Recommended Treatment Strategiesfor the Discharging Patient In those with previously diagnosed diabetes and an elevated A1C level If HbA1C 7-8%: Increase dose of home oral agents, add third agent or add basal insulin at bedtime HbA1C > 8%: If already on two oral agents, add once daily basal insuin at bedtime If HbA1C 9-10%: Patient should be discharged home on basal and bolus insulin regime. Use the amount of basal insulin required in the hospital as once daily glargine/detimer or bid NPH dose. Continue multiple daily dose as started in the hospital if appropriate. Twice daily premixed insulin should be considered for less complex insulin regimens particularly in elderly patients.

11. Recommended Treatment Strategiesfor the Discharging Patient

12. Home regimen prior to admission Admission reason: hypoglycemia?, acute MI?, related to hyperglycemia? (DKA, HHS, etc.) Readmission for diabetes within 30 days New co-morbidities that may limit prior oral therapy Treatment goals Depression? Discharge Considerations forPatients with Known Diabetes It is really easy�One only needs to considerIt is really easy�One only needs to consider

13. Recommended Educational Strategies for the Discharging Patient Education should begin on day 1 or as soon as the patient is appropriate for education based upon patient needs Initiate Inpatient Diabetes Educator consult as early as possible Nursing to reinforce the education as many times as possible utilizing every opportunity (medications, BG result, diet etc.) Involve family members whenever its appropriate Provide education materials to reinforce the teachings and provide community and web resource lists Continue the education on an outpatient basis if needed by referring through the appropriate channel

14. Continuum of Care If new to insulin Referral to an outpatient diabetes educationprogram shortly after discharge to discussongoing diabetes control Discharge Information on when to check BG andtiming of insulin administration. Information shouldalso include parameters for when to call PCP Communication to patients PCP regardingchanges made to patients treatment regime during hospitalization and a complete medication list An assessment of the need for home health care

15. Caution: Possible InsulinMedical Error Ahead Transition from Inpatient to the Outpatient setting represents a crucial break in care Nearly one half of patients may experience a medical error after hospital discharge Elderly patients with recent hospital discharge are at high risk of developing serious hypoglycemia

16. Timely Discharge Information Required by the Receiving PCP Primary and secondary diagnoses; and Diagnostic findings Dates of hospitalization, treatment provided anda summary of hospital course Discharge Medications Patient or family counseling Tests pending at discharge Details of follow-up arrangements The name and contact information of the responsible hospital physician

17. Take Home Message Early identification of patients in need of education Patient has received the necessary skills and training Patient is provided with post discharge plan for diabetes Patient has received clear instructions about medications including name, dosage and when to take them Patient has a scheduled follow-up appointment at time of discharge Written documentation for PCP completed at time of discharge

18. Major Predictor for Appointment Keeping � A direct referral from the Inpatient Staff increased the odds of keeping a follow upvisit by more than 8 fold� �Appointment keeping behavior in the out patient setting is critical to achieving desired glycemic control�