1. Transition of Care in patients with diabetes Medha Munshi, MD Joslin Diabetes Center Beth Israel Deaconess Medical Center Harvard Medical School

2. Case Vignettes 89 yrs old pt –admitted with bilat. PE –on glipizide 5 mg bid at the time of admission –Prolonged and complicated hospital course –Required endocrine consult for difficult to control blood glucose –Discharged to rehab on 3 different scales needed to control BS during the acute illness –Now discharged from rehab to home on the same regimen – returns to the clinic with wide excursions of glucose

3. Case Vignettes 78 yrs old patient, caregiver for husband with dementia, needed various strategies to control BG in the clinic – simplified regimen was started Recently was asked by her cardiologist to go back to basal bolus regimen due to high BS Admitted to the hospital for 14 falls in a month in middle of the night Hypoglycemia ruled out during hospitalization and ALL work up for syncope – negative Found by family to have multiple types of insulin collected over months – patient was taking short acting insulin 50 u at bedtime

4. Transition of care Set of action designed to ensure the coordination and continuity of health care between different locations or different levels of care at the same location Acute care hospital Rehab Home Primary / subspecialty care offices

5. Prevalence 2001 Harris poll by the Robert Wood Johnson Foundation -hospital discharge (>65 yrs) - 23% to another institutions - 11.6% with home care 19% transferred back from SNF to hospital within 30 days 42% transferred within 24 months -older adults with  1 chronic condition see 8 different MDs/year

6. Consequences of Fragmented care Inappropriate or conflicting care recommendations Medication errors Patients/caregiver distress Re-hospitalizations Higher cost of care

7. Barriers to Effective Care Transitional Care for Persons with Complex Care Needs The delivery system The clinician The patient Coleman EA: J Am Geriatr Soc 51:549-555, 2003

8. The Delivery System Level Each institution has a distinct independent delivery system (complicated by HIPAA) Lack of formal communication system Lack of financial incentive promoting transition of care and accountability in fee-for- service Medicare. Different financial and contractual relationships with pharma companies Lack fo quality indicators for transition of care

9. The Clinician Level Different physicians at different locations Productivity pressure on PCP – patients are not followed across the care levels Hospitalization occurs at different locations Care manager and social workers operate independently from primary team – sometimes adds to the confusion

10. The Patient Level Little advocacy or outcry unless family member is confronted with emergency Patient or caregivers are not prepared to optimize care they will receive at the next setting

11. Diabetes-Specific Challenges BG and insulin need change during acute hospitalization BG and insulin need do not return to baseline at the time of discharge Interaction between illness, anorexia, delirium post hospitalization Discomfort felt by medical providers in changing diabetes regimen

12. Diabetes-specific Complications Post-hospitalization Hypoglycemia if insulin dose is not lowered when acute illness resolves, inadequate meals or weight loss Hyperglycemia if inadequate insulin for persisting illness Stress for patient and caregivers if discharged on new regimen/sliding scales

13. Ideal Discharge check-list for elderly patients society of hospital medicine’s hospital quality and patient safety committee Data Elements d/c Summary Patient Instructions Communication HPI Key findings diagnosis 15 elements in total

14. Our Challenge To develop a better system to improve the handoff esp. for patients with diabetes To provide access to a diabetes educator for patient/caregiver for help after hospitalization ( pharmacy clinic is not adequate) To teach providers “transitional diabetes care” To develop care plan that is generalizable to all communities

15. Diabetes regimenReasons for change in regimen from previous Anticipated change in diabetes treatment as patient recover At the time of hospitalization  Oral meds  Fixed dose insulin  Sliding scale regimen At the time of hospital discharge  Oral meds  Fixed dose insulin  Sliding scale regimen  Hyperglycemia due to acute illness  Hypoglycemia due to low oral intake  Fluctuating blood glucose  Oral agent contraindicated  Formulary issues  Discontinue sliding as tolerated  Discontinue insulin as tolerated  Restart oral medications as tolerated  Increase dose of insulin as tolerated  Increase dose of oral meds as tolerated At the time rehabilitation discharge  Oral meds  Fixed dose insulin  Sliding scale regimen  Hyperglycemia due to acute illness  Hypoglycemia due to low oral intake  Fluctuating blood glucose  Oral agent contraindicated  Formulary issues  Discontinue sliding as tolerated  Discontinue insulin as tolerated  Restart oral medications as tolerated  Increase dose of insulin as tolerated  Increase dose of oral meds as tolerated At the time of PCP visit  Oral meds  Fixed dose insulin  Sliding scale regimen

16. Shared Experiences Hospital Long term Care Visiting nurses Others?