1. Quality of Life Matters NOT TOO HIGH… NOT TOO LOW… A PLAN FOR OPTIMIZING DIABETES MANAGEMENT IN NURSING HOMES 1. Introduction

2. Workshop Agenda 0900 – Welcome and Introductions 0915- 11:00 – Module 1 & 2 – Intro to Program and Understanding Diabetes 11:00-11:15 – Bio Break 11:15-12:30 – Module 3 – Blood Glucose Monitoring (best practices) 12:30-1:00 - Lunch 1:00-2:00 – Module 4 Understanding Glycemic Variability 2:00-2:15 – Bio Break 2:15-3:00 – Module 5 & 6 - Insulin Management and Injection Technique 3:00-3:30 – Q&A

3. Curriculum Development: Author: Carol Nicholson RN BN Certified Diabetes Educator (CDE) Project Lead: Dr. Angela McGibbon Research Assistants: Sarah Curtis and Amanda Robichaud, BA This work was made possible through an Innovation Fund Grant 2014-2015 from the NB Department of Health, Chronic Disease Prevention and Management Unit

4. Diabetes Education Modules Module #1 Introduction to Optimizing Diabetes Management in LTC Content The rationale upon which this project has been based Diabetes in the elderly Frailty in the elderly & the role it plays in determining appropriate care National & international standards of care for the frail elderly Education Overview

5. Diabetes Education Modules Module #2 Understanding Diabetes Diabetes Basics “101” CDA Clinical Practice Guidelines Appropriate targets: blood glucose & A1c Frailty Relationship between BG readings & A1c; story they tell re glycemic control Hypoglycemia Hyperglycemia Quality of life Foot care

6. Diabetes Education Modules Module #3 Blood Glucose Monitoring: Best Practices Blood glucose testing tips Decision making re: BGM Hypo, Hyper….how to respond to results Recommended frequency & timing Correlation between BGM & A1c Case studies

7. Diabetes Education Modules Module #4 Understanding Glycemic Variability AKA… Highs/ Lows??? What??? Why??? Reaction/ Action!! Food Activity Oral Medications Insulin Injection technique Illness Stress Hypoglycemia in the elderly: symptoms, causes & prevention

8. Diabetes Education Modules Module #5 Insulin - Part One Insulin Action Types of Insulin – Basal Long Acting – Basal Intermediate Acting – Meal Insulin Rapid Acting – Meal Insulin Short Acting – Mixed Insulins – Hypoglycemia

9. Diabetes in the Frail Elderly

10. NB Diabetes Innovation Project Optimizing Diabetes Management in Long Term Care Grant Sponsor: NB Department of Health, Chronic Disease Prevention and Management, 2015-2016. Project Manager: Jodi Hall, NBANH Advisory Committee: – Dr. Angela McGibbon, Endocrinologist – Carol Nicholson, RN BN CDE, Diabetes Nurse Educator – Shelley Jones, RN BScN CDE, Outreach Diabetes Case Manager – Michelle Corcoran, RD CDE, Outreach Diabetes Educator – Kyla Abernethy, RN BN, Director of Care, Pine Grove Nursing Home

11. Goals of Innovation Project Educate LTC professionals in the nursing home sector to support consistent practice standards and use of best practices in diabetes management of the frail elderly. Support quality of life for residents with diabetes through best practice approaches. Assist NB nursing homes to become a national leader in best practice management of diabetes with the frail elderly in long term care.

12. Prevalence of Diabetes in LTC 20% of individuals living in LTC over the age of 80 will have Type 2 diabetes Individuals with Type 1 are living longer

13. Cost Implications …. Diabetes is associated with increased morbidity and mortality Direct costs associated with diabetes Indirect costs associated with diabetes

15. Standards for Diabetes Management in the Frail Elderly Resources Organizations that set standards for practice: – Canadian Diabetes Association Clinical Practice Guidelines 2013 – American Diabetes Association 2012 – International Diabetes Federation 2013 – European Working Group 2011 – Ontario Health Care Professionals LTC Working Group 2013 – Diabetes Care Program of NS 2010

16. Current standards… CDA CPG 2013 HBA1C 7.1- 8.5% Individualizing Diabetes Care for LTC residents Ontario HBA1C < 8.5% IDF Managing Older People with Type 2 Diabetes Global Guideline (2013) HBA1C 7.0- 8.5% Management of Diabetes in the LTC Population: A Review of the Guidelines. CADTH 2013 HBA1C 8- 9.0 % Diabetes in Older Adults: A consensus report ADA & AGA (2012) HBA1C 8- 9.0% IDF European Working Group HBA1C 7.6- 8.5% VA/DOD (2010) HBA1C 7.0- 9.0% Long Term Care Formulary: Alberta Health Services (Calgary Zone 2013) HBA1C 8.0% or slightly higher Diabetes Care Program of Nova Scotia HBA1C 7.0- 12.0%

21. So let’s have a look…

22. Moorhouse P, Rockwood K. J R Coll Physicians Edinb 2012;42:333-340.

23. Concerns Frequently Seen in LTC FALLS Hypoglycemia Hyperglycemia Confusion re hypo and hyperglycemia…which is of more concern? Blood glucose readings and HBA1c Current standards for the frail elderly.

24. Diabetes Education Modules GOAL …  Individuals caring for the frail elderly will have a better understanding of diabetes…so that all caregivers will know…  when to speak up  where to seek assistance from. DELIVERY… – tailored to recipients’ level, from administrators to personal care workers and all in between.

25. Certified Diabetes Educator What: National Certification Who: RN, RD, Pharm, NP, Physician Where: – Diabetes Education Centers – Community Diabetes Case Managers (HHN & Vitalite) – Primary Health Care NP’s – Community e.g. pharmacies

26. References Sources Building Competency in Diabetes Education: Advancing Practice http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpufhttp://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf Building Competency in Diabetes Education: The Essentials http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpufhttp://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf Calgary Zone Long Term Care Formulary. Alberta Health Services, 2013. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37 (suppl 1):S1-S212. Cook, B., Mallery, L., Harrigan, L. & Ranson, T. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities. Diabetes Care Program of Nova Scotia, 2010. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities Pocket Reference. Diabetes Care Program of Nova Scotia, 2010. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities, Diabetes Care Program of Nova Scotia Supporting Document – Background. Diabetes Care Program of Nova Scotia, 2010. Diabetes Management in the Long Term Care Setting. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 2014. Herzig Mallery, L.,Ransom, T.,Steeves, B. et al (2013). Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program. Journal of the American Medical Directors Association, 14, 801-808. How Diabetes Works Conversation Maps. Healthy I. Copyright 2009 Healthy Interactions Inc. www.diabetes.healthyi.comwww.diabetes.healthyi.com Individualizing Diabetes Care for Long Term Care Residents: A Guidebook. Long Term Care Working Group of Health Care Professionals working in the Central Local Health Integration Network (Ontario), 2013. Kirkman, M., Briscoe, V., Clark, N. et al (2012). Diabetes in Older Adults : A Consensus Report. Journal of the American Geriatrics Society, 60, 2342-2356. Managing Older People With Type 2 Diabetes Global Guideline. International Diabetes Federation, 2013. Management of Diabetes in the Long-Term Care Population: A Review of Guidelines. Canadian Agency for Drugs and Technology in Health, 2013. Self-monitoring of Blood Glucose in People with Type 2 Diabetes: Canadian Diabetes Association Briefing Document for Healthcare Providers. Canadian Journal of Diabetes, Vol. 35, Issue 4, p317–319, 2011 Sinclair, A., Paolisso, G., & Castro, M. (2011). European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive Summary.. Diabetes & Metabolism, 37, S27- S38. Retrieved from http://www.sciencedirectcom. Standards of Medical Care in Diabetes 2013. American Diabetes Association, 2013.