Meeting News

In transition from hospital to home, diabetes educators can take the lead

INDIANAPOLIS — Patients with diabetes seeking acute medical care today are sicker, frailer and have more complex medical conditions and treatment plans, complicating their transition from hospital to home, according to a speaker here.

Adding to this burden, said Virginia Peragallo-Dittko, RN, BC-ADM, CDE, FAADE, executive director of the Diabetes and Obesity Institute at NYU Winthrop Hospital, are increasingly shorter hospital stays, financial pressures to discharge patients, and community systems and care management that cannot keep up or do not exist.

“The model we should be working from doesn’t have the hospital at the top,” Peragallo-Dittko, also professor of medicine at Stony Brook University School of Medicine, said during her presentation at the American Association of Diabetes Educator’s annual meeting. “It has community care at the top. This is where our efforts need to be when we look at transition.”

Transitions have gotten better in recent years, Peragallo-Dittko said. Hospitals are now beginning to look at root causes of admission and transitions now involve early contact with a primary care provider, improved home support, medication access and prompt response to problems. Additionally, patients are now being identified as having diabetes on admission. Still, she said, more resources are needed. Transition models, Peragallo-Dittko said, need to be “upside-down” — from the community setting into the hospital.

Patients, in general, face many obstacles as they are preparing to leave the hospital that are often taken for granted, Peragallo-Dittko said. Discharge instructions — often many pages long — can be overwhelming and complicated. Patients, sometimes out of fear or for cultural reasons, are not comfortable asking questions upon discharge. For many, family members or the primary caregiver may not be present. Their chief concern, Peragallo-Dittko said, could be on something as simple as getting a ride home.

“Patients are ready to go home, and they may not even listen to discharge instructions,” Peragallo-Dittko said. “They’re worried about who is picking them up. Are they going to be on time? I don’t want to stay here another minute; keep talking, but I’m not listening.”

Once the patient leaves, there may be limited social support and limited resources, complicating the ability for self-case. Still, other patients are undocumented and uninsured, further complicating their care after discharge.

“Does anyone know the first fill rate for an insulin prescription on discharge?” Peragallo-Dittko said. “Ten percent, first fill. This is e-prescribed, not a piece of paper that (was misplaced) somewhere. This is sent right to the pharmacy, and 10% of the people pick it up. That is powerful.” The prescription abandonment rate in general, Peragallo-Dittko said, is 65%.

“For some mail order pharmacies ... it takes 2 weeks to get a (blood glucose) meter,” Peragallo-Dittko said. “So, someone who is newly diagnosed, and no meter for 2 weeks. Who do you think is likely to be readmitted?”

The inpatient to outpatient transition of diabetes care is understudied, Peragallo-Dittko said, and diabetes is typically a secondary diagnosis on admission.

“So many times, it’s not even on the mind of the person doing the discharge,” Peragallo-Dittko said.

But problems are persistent in this patient group, who can have problems with glycemic control beginning immediately after discharge, due in part to changes in diet composition and physical activity at home. Incorrect prescriptions, incomplete supplies and barriers to family involvement can make it difficult for even a motivated patient to stay engaged in their care, Peragallo-Dittko said.

Creative solutions exist, Peragallo-Dittko said, including several comprehensive models like Project RED (Re-Engineered Discharge), Project BOOST (Better Outcomes by Optimizing Safe Transitions), and the Homecoming Transitional Care Program in San Francisco. The models involve making follow-up appointments before discharge, planning follow-up for pending test results, identifying correct medicines and plans to obtain them, and telephone reinforcement. Telehealth, in general, Peragallo-Dittko said, has been shown to be effective to reach patients, as have audio discharge instructions that can be accessed via phone (Vocera) and peer visits.

“Remember that this is a vulnerable time period,” Peragallo-Dittko said. “It’s an individualized approach, but it’s a risk-based resource use. This is not one size fits all, and not all resources are for all people.

“I have encountered the thinking of, ‘Well, this is our transition program,’” Peragallo-Dittko said. “No, this is one piece. There’s going to be a transition program with 50 pieces. That tells the team to start to let go of those silos that we’re dealing with.”

Peragallo-Dittko said the adage “it takes a village” applies to transitional care for it to be successful.

“Transitional care is a point in time ... all of our community work is supposed to carry them forward,” Peragallo-Dittko said. “I challenge you to take a look at one patient, or one community, and take your first step.” – by Regina Schaffer

Reference:

Peragallo-Dittko V. Transitioning the patient from hospital to home: It’s complicated. Presented at: American Association of Diabetes Educators; Aug. 4-7, 2017; Indianapolis.

Disclosure: Peragallo-Dittko reports no relevant financial disclosures.

 

INDIANAPOLIS — Patients with diabetes seeking acute medical care today are sicker, frailer and have more complex medical conditions and treatment plans, complicating their transition from hospital to home, according to a speaker here.

Adding to this burden, said Virginia Peragallo-Dittko, RN, BC-ADM, CDE, FAADE, executive director of the Diabetes and Obesity Institute at NYU Winthrop Hospital, are increasingly shorter hospital stays, financial pressures to discharge patients, and community systems and care management that cannot keep up or do not exist.

“The model we should be working from doesn’t have the hospital at the top,” Peragallo-Dittko, also professor of medicine at Stony Brook University School of Medicine, said during her presentation at the American Association of Diabetes Educator’s annual meeting. “It has community care at the top. This is where our efforts need to be when we look at transition.”

Transitions have gotten better in recent years, Peragallo-Dittko said. Hospitals are now beginning to look at root causes of admission and transitions now involve early contact with a primary care provider, improved home support, medication access and prompt response to problems. Additionally, patients are now being identified as having diabetes on admission. Still, she said, more resources are needed. Transition models, Peragallo-Dittko said, need to be “upside-down” — from the community setting into the hospital.

Patients, in general, face many obstacles as they are preparing to leave the hospital that are often taken for granted, Peragallo-Dittko said. Discharge instructions — often many pages long — can be overwhelming and complicated. Patients, sometimes out of fear or for cultural reasons, are not comfortable asking questions upon discharge. For many, family members or the primary caregiver may not be present. Their chief concern, Peragallo-Dittko said, could be on something as simple as getting a ride home.

“Patients are ready to go home, and they may not even listen to discharge instructions,” Peragallo-Dittko said. “They’re worried about who is picking them up. Are they going to be on time? I don’t want to stay here another minute; keep talking, but I’m not listening.”

Once the patient leaves, there may be limited social support and limited resources, complicating the ability for self-case. Still, other patients are undocumented and uninsured, further complicating their care after discharge.

“Does anyone know the first fill rate for an insulin prescription on discharge?” Peragallo-Dittko said. “Ten percent, first fill. This is e-prescribed, not a piece of paper that (was misplaced) somewhere. This is sent right to the pharmacy, and 10% of the people pick it up. That is powerful.” The prescription abandonment rate in general, Peragallo-Dittko said, is 65%.

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“For some mail order pharmacies ... it takes 2 weeks to get a (blood glucose) meter,” Peragallo-Dittko said. “So, someone who is newly diagnosed, and no meter for 2 weeks. Who do you think is likely to be readmitted?”

The inpatient to outpatient transition of diabetes care is understudied, Peragallo-Dittko said, and diabetes is typically a secondary diagnosis on admission.

“So many times, it’s not even on the mind of the person doing the discharge,” Peragallo-Dittko said.

But problems are persistent in this patient group, who can have problems with glycemic control beginning immediately after discharge, due in part to changes in diet composition and physical activity at home. Incorrect prescriptions, incomplete supplies and barriers to family involvement can make it difficult for even a motivated patient to stay engaged in their care, Peragallo-Dittko said.

Creative solutions exist, Peragallo-Dittko said, including several comprehensive models like Project RED (Re-Engineered Discharge), Project BOOST (Better Outcomes by Optimizing Safe Transitions), and the Homecoming Transitional Care Program in San Francisco. The models involve making follow-up appointments before discharge, planning follow-up for pending test results, identifying correct medicines and plans to obtain them, and telephone reinforcement. Telehealth, in general, Peragallo-Dittko said, has been shown to be effective to reach patients, as have audio discharge instructions that can be accessed via phone (Vocera) and peer visits.

“Remember that this is a vulnerable time period,” Peragallo-Dittko said. “It’s an individualized approach, but it’s a risk-based resource use. This is not one size fits all, and not all resources are for all people.

“I have encountered the thinking of, ‘Well, this is our transition program,’” Peragallo-Dittko said. “No, this is one piece. There’s going to be a transition program with 50 pieces. That tells the team to start to let go of those silos that we’re dealing with.”

Peragallo-Dittko said the adage “it takes a village” applies to transitional care for it to be successful.

“Transitional care is a point in time ... all of our community work is supposed to carry them forward,” Peragallo-Dittko said. “I challenge you to take a look at one patient, or one community, and take your first step.” – by Regina Schaffer

Reference:

Peragallo-Dittko V. Transitioning the patient from hospital to home: It’s complicated. Presented at: American Association of Diabetes Educators; Aug. 4-7, 2017; Indianapolis.

Disclosure: Peragallo-Dittko reports no relevant financial disclosures.

 

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