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FORUM - Translating research into quality health care for Veterans

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Research Highlight

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.

  1. 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.
  2. 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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