Improving diabetes care and patient outcomes in skilled-care communities: successes and lessons from a quality improvement initiative.

OBJECTIVE

To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease.

DESIGN

Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences.

SETTING

Two skilled-nursing LTC communities.

PARTICIPANTS

Physicians, administrators, nurses, certified nursing assistants, and nutrition staff.

INTERVENTION

Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals.

MEASUREMENTS

Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education.

RESULTS

The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity.

CONCLUSION

Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders.