1. 1 Module 7 Discharge Planning Managing the Transition from Inpatient to Outpatient Care Diabetes Special Interest Group Georgia Hospital Association

2. 2 In this module we will discuss discharge planning Learning Modules Module no.Topic 1Hyperglycemia and hospital outcomes 2Challenges and opportunities for care improvement 3Initial recognition, triaging, and management 4Principles of pharmacologic management: Insulin 1 5Principles of pharmacologic management: Insulin 2 6Review of policies and procedures 7Preparing patients for discharge

3. 3 Objectives Discuss the importance of transition Identify factors related to better follow-up outcomes Discuss the importance of starting the discharge plan at the time of the admission List criteria you should know about your patient Identify what should be done to make sure the diabetes patient is ready to be discharged

4. 4 The Three Phases of Inpatient Hyperglycemia Care Admission First 24 hours Recognition and triage Initial treatment plan Continued care Ongoing monitoring education treatment adjustment Discharge planning What therapy? What is the follow-up? Do patients know what to do? Education provided? Think about what you will need for discharge as soon as possible after the patient is admitted

5. 5 Diabetes Discharges1999 to 2005 Hospital X We will be seeing more inpatients with hyperglycemia and hopefully more resources for outpatient continuing diabetes education

6. 6 Survival Skills Should Be Instructed Prior to Discharge The following survival skills are instructed at Hospital Y: Define diabetes in simple terms State own type of diabetes Describe basic functions of pancreas, insulin and glucose metabolism Describe what happens when insulin is not available or is not working properly

7. 7 Survival Skills Continued Identify family/SO role in managing diabetes Describe one day sample menu Name 3 food groups that are high in carbohydrates State appropriate timing of food related to medication State food choice for specific exercise/duration

8. 8 Survival Skills Continued State relationship of exercise to blood glucose State correct name, dose, onset, peak, duration, side effects, and time to take medication Correctly draw up and administer insulin Explain site selection and rotation of insulin injections

9. 9 Survival Skills continued State need for insulin on sick days Describe safe needle disposal State purpose of testing Perform monitoring correctly Interpret results Log blood sugar results

10. 10 Survival Skills Continued State frequency of monitoring Cite who and when to contact with results State when to monitor ketones Describe safe lancet disposal State relationship between nutrition, exercise, medication and blood glucose levels State the causes, signs and symptoms of hyperglycemia

11. 11 Survival Skills Continued Explain the proper treatment of hyperglycemia State the causes, signs, and symptoms of hypoglycemia Explain proper treatment of hypoglycemia State when to call healthcare provider State where follow-up care will be provided These objectives align with ADA approved curriculum such as Life with Diabetes, Third Edition, A Series of Teaching Outlines by the University of Michigan Diabetes Research and Training Center.

12. 12 What Do You Know About Your Patient? Location –Non-ICU –ICU Demographics –Age –LOS –Sex –Race/ethnicity –Payor

13. 13 What do you know about your patient? Continued Healthcare resources –Community resources –Family support Barriers to education and self-care –Mental status –General health and dexterity

14. 14 Admission Discharge Outpatients Follow-up Lost to follow-up Model Of Continuum of Diabetes Care From Wheeler K Archives of Internal Medicine 2004;164:447-453

15. 15 Inpatient To Outpatient Transfer Of Diabetes Care: Why Is It Important? Ambulatory settings are the most common site of care Outpatient visits are the majority of physician contacts Patients who receive integrated outpatient diabetes care have better outcomes Regulation –National patient safety goal –Part of new Joint Commission’s requirement for program certification in inpatient diabetes

16. 16 Appointment Adherence Correlates with Better Glycemic Outcomes From Rhee MK et. al. Diabetes Educator 2005; 31:240-250. Grady Diabetes Clinic, 1,560 Patients, 1991  2001

17. 17 Joint Commission Statement National Patient Safety Goals Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions (2E) A complete list of the patient’s medications is communicated to the next provider of service (8B) –The complete list of medications is also provided to the patient on discharge from the facility Plan for post-discharge education or self- management support (needed for disease specific certification)

18. 18 A Specific Hand-Off (Direct Referral) at Discharge Is Key to Ensuring Follow-Up 658 patients discharged from Grady Memorial Hospital, 2001 From Wheeler K Archives of Internal Medicine 2004;164:447-453

19. 19 Self-Reported Barriers to Post-Discharge Follow-Up 303 inpatients at Grady Memorial Hospital, 2002 Most (95%) planned to have post-discharge follow-up, but…50% anticipated they would have problems doing so. Wheeler K et. al. Ethnicity and Disease, in press

20. 20 Variables Associated with Anticipating a Barrier To a Post Discharge Follow-Up Visit Odds ratio 95% confidence intervalP value Women vs. men2.301.12-4.73.024 Uninsured vs. insured2.621.04-6.57.040 Prior health care access trouble vs. no trouble 5.942.88-12.23<.0001 Retired vs. employed4.550.83-25.01.081 College vs. high school0.470.19-1.15.098

21. 21 What You Can Do To Make Sure Your Patient Is Ready for Discharge Assess patient’s educational needs on admission (What does the patient already know?) Assess potential barriers to self-care Assess potential barriers to follow-up Determine follow-up (Who? Where? When?) What will the therapy be at discharge? Maximize level of glycemic control

22. 22 Utilize Existing Hospital Resources Inpatient Diabetes Education You must anticipate the need for education at the beginning, not the end of the hospital stay Social Work Your hospital most likely does not have a rapid-response diabetes education team

23. 23 Discharge Documentation Diabetes/hyperglycemia Level of inpatient glycemic control Whether education received What the follow-up will be –Who –When –Where Discharge therapy

24. 24 Lecture Series Summary Identify the patient with hyperglycemia early in the hospitalization Treating hyperglycemia improves hospital outcomes There are systematic ways to estimate insulin requirements—avoid clinical inertia Your hospital’s policies and procedures relating to diabetes Make sure patient is ready for discharge