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The need for access to high quality chronic disease management is at an all-time high
and stretching limited provider resources.
Models that focus on use of the entire
clinical team are needed to enhance access
while improving coordination of care. In
2003, the Veterans Health Administration
(VHA) introduced a national Home
Telehealth (HT) system as a comprehensive,
cost-effective, and well-received
method for providing care coordination
to a burgeoning chronic disease Veteran
population.1 For patients with diabetes,
care coordination optimizes chronic disease
management through daily end user
messaging, education, and communication
between Veterans and healthcare nurses.
In 2011, at the Mann-Grandstaff VAMC, an
influx of HT referrals for diabetic management
prompted development of a systematic
approach to improve care by implementing
insulin adjustment standing orders that utilized
the Veterans Affairs/Department of Defense
(VA/DoD) Diabetes Clinical Practice
Guidelines. Using the standing medication
order, HT RN case managers provided safe
and expedient resolution of blood glucose
fluctuations on a real-time basis.
A Performance Improvement Project undertaken
by the Mann-Grandstaff VAMC
HT staff evaluated the effect of RN real-time
insulin adjustment over a six month period
using a quasi-experimental design comparing
historical controls from a 2009 cohort
(n=28) with the quality improvement intervention
patients (n=24). They established the
outcome variable as time to achieving A1C
target. The project found a statistically significant
improvement in time to reach target
for the intervention cohort, as compared to
the historical cohort. The RN standing orders
group accomplished this more efficiently,
with a decrease in the average time to reach
individual glycemic goal from 258 days to 89
days, a 66 percent improvement.
With this success, the Mann-Grandstaff
VAMC expanded RN standing orders in
2013 to create a more flexible, comprehensive
Insulin Adjustment Protocol for
HT RN Case Managers. RNs who were
approved to use the protocol received 12
hours of didactic diabetic education, as
well as mentoring and real-time decision
support. Once Insulin Adjustment Protocol
orders were written, HT RNs began
utilizing it as part of their chronic disease
management. Initially, they consulted regularly
with the nurse practitioner advisor
to transfer didactic learning into clinical
application by jointly analyzing blood glucose
patterns, developing in-depth understanding
of the mechanisms of different
insulins, the basal/bolus ratio concept, and
determining how much, and what type, of
insulin adjustment to make.
Concurrently, the Veterans Administration
(VA) Office of Nursing Service (ONS)
undertook a review of RN Case Manager
research literature while designing a new
model of chronic care delivery remarkably
similar to the Mann-Grandstaff RN
medication protocol. Several of the VHA
medical diabetes experts expressed concern
regarding RNs adjusting insulin with
potential risk of adverse hypoglycemic
events. To ensure Insulin Adjustment
Protocol safety, ONS provided funding to
harvest and analyze the RN insulin titration
program.
The hypoglycemia evaluation included all
patients with diabetes on insulin (n=155)
enrolled in the program on August 1,
2014, with primary outcome variables
being the occurrence of hypoglycemia and
A1C reduction. Hypoglycemia was based
on values from glucose self-monitoring
(stratified by 50-70 and < 50 mg/dL) plus
ER visits. Researchers compiled data on
patient age, length of time since diagnosis
of diabetes, comorbidities, medications,
number of low blood sugar readings, and
the reason for the low blood sugar from
vendor data and chart reviews. The mean
age for patients enrolled in the RN protocol
group was 66 and the mean duration of
diabetes was 11 years. A high prevalence of
baseline basal insulin use suggests that the
RN protocol was implemented in a complex
diabetes population.
Results from a paired t-test using Minitab
16 Statistical Software program indicated
a significant difference in the reduction in
A1C from entry into the program to finish
with the RN managed insulin titration
protocol. The mean baseline A1C was 9.6
percent and the final mean A1C was 7.7
percent. Mild hypoglycemia was present
during the RN titration of insulin management.
Serious hypoglycemia was very uncommon
(n=2). The evaluation found no
acute care admissions or ER visits for hypoglycemia.
The evaluation further identified
missed meals and increased activity
as common causes for hypoglycemia with
no such instances related to an RN insulin
adjustment.2 These findings demonstrate
safety and efficacy in a model of care focusing
on use of RN clinical team members
working to the top of their license and
improving quality of care in chronic disease
management of an older population
of patients with long standing diabetes.
- Darkins A, et al. "Care Coordination/Home Telehealth:
the Systematic Implementation of Health
Informatics, Home Telehealth, and Disease Management
to Support the Care of Veteran Patients
with Chronic Conditions," Telemedicine Journal
and E-Health 2008; 14(10):1118-26.
- Brown N, et al. "RN Diabetes Virtual Case Management:
A New Model for Providing Chronic
Care Management," Nursing Administration
Quarterly 2016; 40(1):60-7.
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