Specialized care improves outcomes for diabetics
Partnership with endocrinology practice is a win-win
Reducing emergency department visits for all home health patients is a key factor in improving outcomes and ensuring good reimbursement under a pay for performance system. Home health patients with diabetes present a special challenge because even without a primary admission diagnosis of diabetes, the home health staff must take steps to ensure control of the diabetes in order to ensure a good outcome for other diagnoses.
"Our patients have multiple co-morbidities, but we make sure that all staff members and case managers understand that uncontrolled diabetes can affect all other conditions," says Amy Hartman, RN, BSN, director of nursing at Willow Creek Health Care in Salt Lake City. A rigorous staff education program that focuses on diabetes care along with an emphasis on ongoing patient education is one step that the agency has taken to improve outcomes for patients with diabetes. "We've also partnered with a local endocrinology practice to make sure that all of our patients have access to a physician with an expertise in diabetes," she adds.
The local endocrinology practice sees a number of home health patients and also encounters patients who may need home health service, points out Hartman. In fact, the endocrinology practice started their diabetes outreach service that included home visits by a physician or a nurse practitioner to offer closer monitoring to diabetic patients, she says. Because the physician practice already had a home visit service, it was very easy for the two organizations to collaborate, she explains. "They will refer patients to us if one of their patients needs more than diabetic care and if one of our patients needs physician care for diabetes, we'll refer patients to their practice," she adds.
The relationship between the two organizations is very helpful in reducing emergency department visits for home health patients, says Hartman. "We now have access to the physician if one of our patients is unstable and needs extra care," she says.
"We also have access to the on-call endocrinologist if one of our patients is in crisis," says Hartman. The ability to treat a hypoglycemic patient with consultation by the endocrinologist has reduced the number of emergency department visits for hypoglycemia to zero, she points out.
There was some resistance to the inclusion of an endocrinologist in the care team for some patients' primary care physicians, admits Hartman. "Some physicians were reluctant to lose control of their patients' plan of care and others were concerned about the type and level of communication they'd have with the endocrinologist," she explains. Because multi-disciplinary team meetings occur weekly and the primary care physician receives monthly updates based on these meetings, the communication fears were alleviated, she says. "Of course, the primary care physician is notified if there is any change in the plan of care," she adds. "The endocrinologist also sends a clinical note to the physician once a month as well," she says.
Now that primary care physicians have seen improved compliance with monitoring and medication and improved outcomes, they are happy with the program, says Hartman. Although patients receive specialized care for diabetes, the focus of the program is improved education and encouragement of self-management, she points out. "We see a lot of patients that have diabetes in addition to their admission diagnosis, and this partnership enables us to meet all of their needs."
Source
For more information about a diabetes program partnership with endocrinologist, contact:
- Amy Hartman, RN, BSN, Director of Nursing, Willow Creek Health Care, Willow Creek Home Health & Hospice, 1935 East Vine Street, Suite 420, Salt Lake City, UT 84121. Telephone: (801) 281-9669. Fax: (801) 281-0179. E-mail: [email protected].
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