| Principal Investigator: | Kim Hall, RN, BSN |
| Organization: | Audie L. Murphy VA Hospital |
Abstract
Evidence
Scientific studies have revealed that patients who receive intensive disease management achieve improved disease management impacting positive long term effects. A pilot study of 20 high risk elderly patients with parameters of very high HgA1c (over 10), non-adherence with medications, diet, exercise and frequent ER visits were trended as variables. Data was collected from the patient’s computerized chart, CPRS and spool for both ER visits and lab results of HgA1c values.
Strategy
Because an individualized diabetes care plan with weekly telephonic contact may result in better diabetes management, a point of contact person is identified to field questions, concerns and issues related to diabetes. In addition other strategies are used to tailor care for the diabetic patient.
Practice Change
The collaborative efforts of the diabetes care plan enabled the diabetic team to evaluate patient progress and resolve problems i.e. exercise equipment and programs, community resources, adjustments to medication and diet.
Evaluation
The outcomes measured were: HgA1c, self monitoring of blood glucose levels provided by patient, three day food logs provided by the patient, exercise and activity level assessment, medication adherence, and dietary intake with correlation to blood glucose levels.
Results
Increased adherence to blood glucose monitoring, activity/exercise attainment levels, dietary changes, decreased HgA1c levels, increase compliance to medication, minimal change in ER visits were trended and analyzed.
Recommendations
Incorporate intensive disease education initially and continue to strategize for attainment of optimal clinical outcomes while encouraging self care of patients with diabetes. Implement interventions such as frequent telephonic contact, telehealth programs and exercise programs to support the patient in achieving glycemic control as a long term goal of care in disease management. Integrate a multidisciplinary approach to disease management resulting in enhanced clinical outcomes that show biggest promise of long term benefits.
Bibliography
- Rothman, Russell L.; Elasy, Tom A. Can diabetes management programs create sustained improvements in disease outcomes? CMAJ Canadian Medical Association Journal. 173(12):1467–1468, December 6, 2005.