Strategies for Effective Discharge Strategies for Effective Discharge Planning for Hospitalized Patients With Planning for Hospitalized Patients With

DiabetesDiabetes

Strategies for Effective Discharge Strategies for Effective Discharge Planning for Hospitalized Patients With Planning for Hospitalized Patients With

DiabetesDiabetes

1

Gaps in US Hospital Discharge Planning Gaps in US Hospital Discharge Planning and Transitional Careand Transitional Care

Base: Adults with any chronic condition hospitalized in past 2 yearsBase: Adults with any chronic condition hospitalized in past 2 years

Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults. EL3, survey.

Know who to contact for questions about condition or treatment

Receive written plan for care after discharge

Receive instructions about symptoms and when to seek further care

Have arrangements made for follow-up visits with any doctor

Have any discharge gap

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Discharge Planning ChallengesDischarge Planning Challenges

• Pressures to discharge patient earlyPressures to discharge patient early• Shorter hospital staysShorter hospital stays• Competing prioritiesCompeting priorities• Lack of primary care physicianLack of primary care physician• Nursing workloadNursing workload• Lack of diabetes specialist educatorLack of diabetes specialist educator• Weekend dischargesWeekend discharges

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Care Coordination for Patients With Care Coordination for Patients With Hyperglycemia/DiabetesHyperglycemia/Diabetes

Moghissi E, et al. Endocr Pract. 2009;15:353-369. 4

Transition From Hospital Transition From Hospital to Outpatient Careto Outpatient Care

• Preparation for transition to the outpatient Preparation for transition to the outpatient setting should begin at the time of hospital setting should begin at the time of hospital admissionadmission

• Multidisciplinary teamMultidisciplinary team– Bedside nurseBedside nurse– Clinical pharmacistClinical pharmacist– Registered dietitianRegistered dietitian– Case managerCase manager

• Clear communication with outpatient providers is Clear communication with outpatient providers is critical for ensuring safe and successful critical for ensuring safe and successful transition to outpatient managementtransition to outpatient management

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 5

Discharge ConsiderationsDischarge Considerations

• What are your discharge plans for this patient?What are your discharge plans for this patient?• Will they be discharged on insulin therapy? Will they be discharged on insulin therapy? • When and where will follow-up take place?When and where will follow-up take place?• What education do they need prior to discharge?What education do they need prior to discharge?

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Preadmission Factors to Be Considered Preadmission Factors to Be Considered in Discharge Planning in Discharge Planning

• Physical/self-care limitations: blindness, stroke, Physical/self-care limitations: blindness, stroke, amputation, dexterityamputation, dexterity

• Socioeconomic factors: insurance coverage, Socioeconomic factors: insurance coverage, family supportfamily support

• Access to follow-up care: PCP, other HCPsAccess to follow-up care: PCP, other HCPs• Degree of glycemic control prior to admission Degree of glycemic control prior to admission

and severity of hyperglycemia and severity of hyperglycemia • Learning issues: language, cognition, Learning issues: language, cognition,

competence related to diabetes self-competence related to diabetes self-managementmanagement

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Functional Health Literacy and Functional Health Literacy and Understanding of Medications at Understanding of Medications at

DischargeDischarge172 patients discharged from community-based teaching hospital with 172 patients discharged from community-based teaching hospital with

prescriptions for 1 or more new medicationsprescriptions for 1 or more new medications

Maniaci MJ, et al. Mayo Clin Proc. 2008;83:554-558.

Recalled being told of ANY possible adverse effects

Could name ≥1 possible adverse effect

Knew dose

Knew medication purpose

Knew medication name

Knew dosing schedule

Aware that new medications had been prescribed

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Relationship Between Inpatient and Relationship Between Inpatient and Outpatient Diabetes ManagementOutpatient Diabetes Management

Inpatient

Compliance with glycemic goals depends on physicians, nursing, and hospital staff

Inpatient

Compliance with glycemic goals depends on physicians, nursing, and hospital staff

Outpatient

Compliance with glycemic goals depends on the patient

Outpatient

Compliance with glycemic goals depends on the patient

Lessons learned in the hospital can impact patient self-care behavior at home

Care received in the outpatient setting can affect need for hospitalization

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Predischarge ChecklistPredischarge Checklist

• Diet informationDiet information• Monitor/strips and prescriptionMonitor/strips and prescription• Prescription for/supplies of medications, insulin, Prescription for/supplies of medications, insulin,

needlesneedles• Treatment goalsTreatment goals• Contact phone numbersContact phone numbers• Medi-alert bracelet Medi-alert bracelet • Survival skills trainingSurvival skills training

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Nursing + Care Coordination: Nursing + Care Coordination: Survival Skills to Be Taught Before Survival Skills to Be Taught Before

DischargeDischarge• How and when to take How and when to take

medication/insulinmedication/insulin– Effects of medicationEffects of medication

• How/when to test blood How/when to test blood glucose (SMBG)glucose (SMBG)– Target glucose levelsTarget glucose levels

• Meal planning basicsMeal planning basics

• How to treat How to treat hypoglycemiahypoglycemia

• Sick-day management Sick-day management planplan

• Date/time of follow-up Date/time of follow-up visitsvisits– Including diabetes Including diabetes

educationeducation

• When and whom to call When and whom to call on the healthcare teamon the healthcare team– Available community Available community

resourcesresources

Moghissi ES, et al. Endocr Pract. 2009;15:353-369. 11

Discharge Planning Depending Discharge Planning Depending on Etiology of Hyperglycemiaon Etiology of Hyperglycemia

Previously DiagnosedDiabetes

• Assess level of control• Adjust therapy as needed• Assess for complications• Outpatient follow-up

Previously DiagnosedDiabetes

• Assess level of control• Adjust therapy as needed• Assess for complications• Outpatient follow-up

TemporaryHyperglycemia

• Resolves in hospital• Requires follow-up

testing

TemporaryHyperglycemia

• Resolves in hospital• Requires follow-up

testing

Previously Undiagnosed Diabetes• Plan to confirm

diagnosis, implement therapy and education

Previously Undiagnosed Diabetes• Plan to confirm

diagnosis, implement therapy and education

Inpatient Inpatient HyperglycemiaHyperglycemia

Fonseca V. Endocr Pract. 2006;12(suppl 3):108-111.Garber A, et al. Endocr Pract. 2004;10:77-82. 12

A1C Is Helpful in DeterminingA1C Is Helpful in DeterminingPost-discharge TreatmentPost-discharge Treatment

• Differentation between hospital-related hyperglycemia and Differentation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (FPG, 2-h undiagnosed diabetes requires follow-up testing (FPG, 2-h OGTT) once patient is metabolically stable using established OGTT) once patient is metabolically stable using established criteria criteria

A1C Indication

≥6.5% • Incipient diabetes• Refer to diabetes educator to begin self-management

education prior to discharge

5.5%-6.4% • Increased risk for diabetes• Prior to discharge, address implementation of lifestyle

interventions that promote weight loss and increased activity

Patients Without Previously Diagnosed DiabetesPatients Without Previously Diagnosed Diabetes

AACE. Endocr Pract. 2011;17(suppl 2):1-53.ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 13

Patients Newly Diagnosed WithPatients Newly Diagnosed WithDiabetes During HospitalizationDiabetes During Hospitalization

• Develop a diabetes education plan prior to hospital Develop a diabetes education plan prior to hospital discharge that addresses the following:discharge that addresses the following:– Understanding of the diagnosis of diabetesUnderstanding of the diagnosis of diabetes– SMBG and explanation of home blood glucose goalsSMBG and explanation of home blood glucose goals– Definition, recognition, treatment, and prevention of Definition, recognition, treatment, and prevention of

hyperglycemia and hypoglycemiahyperglycemia and hypoglycemia– Identification of healthcare provider who will provide Identification of healthcare provider who will provide

diabetes care after dischargediabetes care after discharge– Information on consistent eating patternsInformation on consistent eating patterns– When and how to take medication, including proper When and how to take medication, including proper

disposal of needles and syringesdisposal of needles and syringes– Sick-day managementSick-day management

ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. 14

Discharging Patients With Discharging Patients With Previously Diagnosed DiabetesPreviously Diagnosed Diabetes

• Resume preadmission diabetes regimen at time of Resume preadmission diabetes regimen at time of discharge for patients with acceptable preadmission discharge for patients with acceptable preadmission glycemic control and no contraindication to prior therapy glycemic control and no contraindication to prior therapy

• Modify preadmission therapy for patients identified as Modify preadmission therapy for patients identified as being in poor controlbeing in poor control

• Provide patient and family members/caregivers with Provide patient and family members/caregivers with written and oral instructions regarding glycemic written and oral instructions regarding glycemic management regimen at time of hospital dischargemanagement regimen at time of hospital discharge

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 15

A1C Is Helpful in DeterminingA1C Is Helpful in DeterminingPost-discharge TreatmentPost-discharge Treatment

A1C Indication

6.5%-7.5% Options:•Increase dose of home noninsulin agents•Add third agent•Add basal insulin at bedtime

7.6%-9.0% • If already on 2 noninsulin agents, add once daily basal insuin at bedtime

≥9% • Discharge home on basal and bolus insulin regimen• May use amount of basal insulin required in hospital as once

daily glargine/detemir or twice daily NPH dose• Continue multiple daily doses as started in the hospital if

appropriate• Twice daily premixed insulin may be considered for less

complex insulin regimens, particularly in elderly patients

Patients With Previously Diagnosed DiabetesPatients With Previously Diagnosed Diabetes

Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.Rodbard HW, et al. Endocr Pract. 2009;15:540-559. 16

A1C 6.5%-7.5%**

Monotherapy

MET +

GLP-1 or DPP41

TZD2

Glinide or SU5

TZD + GLP-1 or DPP41

MET +Colesevelam

AGI3

2-3 Mos.***

2-3 Mos.***

2 - 3 Mos.***

Dual Therapy

MET +

GLP-1 or

DPP4 1+

TZD2

Glinide or SU4,7

A1C >9.0%

No Symptoms

Drug Naive Under Treatment

INSULIN

± Other

Agent(s)6

Symptoms

INSULIN

± Other

Agent(s)6

INSULIN

± Other

Agent(s)6

Triple Therapy

AACE/ACE Algorithm for Glycemic Control Committee

Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE

Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE

* May not be appropriate for all patients** For patients with diabetes and A1C <6.5%,

pharmacologic Rx may be considered*** If A1C goal not achieved safely

† Preferred initial agent

1 DPP4 if PPG and FPG or GLP-1 if PPG

2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)

3 AGI if PPG

4 Glinide if PPG or SU if FPG

5 Low-dose secretagogue recommended

6 a) Discontinue insulin secretagoguewith multidose insulin

b) Can use pramlintide with prandial insulin

7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4

8 If A1C <8.5%, combination Rx with agents that cause hypoglycemia should be used with caution

9 If A1C >8.5%, in patients on dual therapy,insulin should be considered

MET +

GLP-1

or DPP41 ± SU7

TZD2

GLP-1

or DPP41 ± TZD2

A1C 7.6%-9.0%

Dual Therapy8

2-3 Mos.***

2-3 Mos.***

Triple Therapy 9

INSULIN

± Other

Agent(s)6

MET +

GLP-1 or DPP41

or TZD2

SU or Glinide4,5

MET +

GLP-1

or DPP41 + TZD2

GLP-1

or DPP41 + SU7

TZD 2

MET† DPP41 GLP-1 TZD2 AGI3

© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE.

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* The abbreviations used here correspond to those used on the algorithm (Fig. 1).** The term ‘glinide’ includes both repaglinide and nateglinide.

Benefits are classified according to major effects on fasting glucose, postprandial glucose, and nonalcoholic fatty liver disease (NAFLD). Eightbroad categories of risks are summarized. The intensity of the background shading of the cells reflects relative importance of the benefit or risk.*

© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

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Recommended Educational Strategies Recommended Educational Strategies for Inpatients Prior to and at Dischargefor Inpatients Prior to and at Discharge

• Begin education on day 1 or as soon as the patient is able Begin education on day 1 or as soon as the patient is able to participateto participate

• Initiate inpatient diabetes educator consult as early as Initiate inpatient diabetes educator consult as early as possiblepossible

• Nursing to reinforce the education as many times as Nursing to reinforce the education as many times as possible utilizing every opportunity (medications, BG result, possible utilizing every opportunity (medications, BG result, diet, etc.)diet, etc.)

• Involve family members whenever appropriateInvolve family members whenever appropriate• Provide education materials to reinforce teachings and Provide education materials to reinforce teachings and

provide community and Web resource listsprovide community and Web resource lists• Continue education on an outpatient basis if needed by Continue education on an outpatient basis if needed by

referring through appropriate channelsreferring through appropriate channels19

Continuum of Care:Continuum of Care:Patients New to InsulinPatients New to Insulin

• Refer to an outpatient diabetes education program Refer to an outpatient diabetes education program shortly after discharge to discuss ongoing diabetes shortly after discharge to discuss ongoing diabetes controlcontrol

• Provide discharge informationProvide discharge information– When to check BGWhen to check BG– Timing of insulin administrationTiming of insulin administration– When to call PCP (eg, symptoms of hypoglycemia)When to call PCP (eg, symptoms of hypoglycemia)

• Communicate with patient’s PCPCommunicate with patient’s PCP– Changes made to patient’s treatment regimen during Changes made to patient’s treatment regimen during

hospitalizationhospitalization– Complete medication listComplete medication list

• Assess need for home health careAssess need for home health care20

Timely Discharge Information Required Timely Discharge Information Required by the Receiving PCPby the Receiving PCP

• Primary and secondary diagnoses and diagnostic Primary and secondary diagnoses and diagnostic findingsfindings

• Dates of hospitalization, treatment provided, andDates of hospitalization, treatment provided, anda summary of hospital coursea summary of hospital course

• Discharge medicationsDischarge medications• Patient or family counselingPatient or family counseling• Tests pending at dischargeTests pending at discharge• Details of follow-up arrangementsDetails of follow-up arrangements• Name and contact information of the responsible Name and contact information of the responsible

hospital physicianhospital physician21

Mortality at 1 year

Lipska K, et al. Circ Cardiovasc Qual Outcomes. 2010;3:236-242.

8751 Medicare beneficiaries with diabetes and AMI admitted on antihyperglycemic therapy

8751 Medicare beneficiaries with diabetes and AMI admitted on antihyperglycemic therapy

7581 discharged ON antihyperglycemic

therapy

7581 discharged ON antihyperglycemic

therapy

1170 discharged OFF antihyperglycemic

therapy

1170 discharged OFF antihyperglycemic

therapy

Unadjusted

HR P

1.47(1.32-1.64)

<0.001

Patients discharged OFF vs. discharged ON antihyperglycemic therapy

Adjusted

HR P

1.29(1.15-1.45)

<0.001

Cox Proportional Hazards Regression

S

urvi

val

0.7

0.

8

0.9

1.

0

Days from Discharge

Diabetes drugs at dischargeYES NO

0 50 100 150 200 250 300 350

Failure to Restart Diabetes Medications and Failure to Restart Diabetes Medications and Outcomes in Older Patients After Acute MIOutcomes in Older Patients After Acute MI

22

SummarySummary

• Patient’s need for diabetes education has been Patient’s need for diabetes education has been assessed (preferably upon admission)assessed (preferably upon admission)

• Patient has received the necessary skills and trainingPatient has received the necessary skills and training• Patient is provided with post-discharge plan for diabetesPatient is provided with post-discharge plan for diabetes• Patient has received clear instructions about medicationsPatient has received clear instructions about medications

– NameName– DosageDosage– When to take themWhen to take them

• Patient has a scheduled follow-up appointment at time of Patient has a scheduled follow-up appointment at time of dischargedischarge

• Written documentation for PCP is completed at time of Written documentation for PCP is completed at time of dischargedischarge

Discharge Checklist for Patients with Inpatient HyperglycemiaDischarge Checklist for Patients with Inpatient Hyperglycemia

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