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Module 7Discharge Planning

Managing the Transition from Inpatient to Outpatient Care

Diabetes Special Interest Group

Georgia Hospital Association

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In this module we will discuss discharge planning

Learning Modules

Module no. Topic

1 Hyperglycemia and hospital outcomes

2 Challenges and opportunities for care improvement

3 Initial recognition, triaging, and management

4 Principles of pharmacologic management: Insulin 1

5 Principles of pharmacologic management: Insulin 2

6 Review of policies and procedures

7 Preparing patients for discharge

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Objectives

• Discuss the importance of transition• Identify factors related to better follow-up

outcomes• Discuss the importance of starting the discharge

plan at the time of the admission• List criteria you should know about your patient• Identify what should be done to make sure the

diabetes patient is ready to be discharged

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The Three Phases of Inpatient Hyperglycemia Care

Admission

First 24 hours Continued care

Recognition and triageInitial treatment plan

Ongoing monitoringeducation

treatment adjustment

Discharge planning

What therapy?What is the follow-up?

Do patients knowwhat to do?

Education provided?

Think about what you will need for discharge as soon as possible after the patient is admitted

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Diabetes Discharges1999 to 2005Hospital X

We will be seeing more

inpatients with hyperglycemia and hopefully

more resources for

outpatient continuing diabetes

education

0

500

1000

1500

2000

2500

3000

1999 2000 2001 2002 2003 2004 2005 2006

Year

Nu

mb

er o

f d

isch

arg

es

10

12

14

16

18

20

1999 2000 2001 2002 2003 2004 2005 2006

Year

% o

f to

tal

dis

char

ges

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Survival Skills Should Be Instructed Prior to Discharge

The following survival skills are instructed at Hospital Y:

• Define diabetes in simple terms• State own type of diabetes• Describe basic functions of pancreas,

insulin and glucose metabolism• Describe what happens when insulin is

not available or is not working properly

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Survival Skills Continued

• Identify family/SO role in managing diabetes

• Describe one day sample menu

• Name 3 food groups that are high in carbohydrates

• State appropriate timing of food related to medication

• State food choice for specific exercise/duration

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Survival Skills Continued

• State relationship of exercise to blood glucose

• State correct name, dose, onset, peak, duration, side effects, and time to take medication

• Correctly draw up and administer insulin

• Explain site selection and rotation of insulin injections

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Survival Skills continued

• State need for insulin on sick days

• Describe safe needle disposal

• State purpose of testing

• Perform monitoring correctly

• Interpret results

• Log blood sugar results

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Survival Skills Continued

• State frequency of monitoring• Cite who and when to contact with results• State when to monitor ketones• Describe safe lancet disposal• State relationship between nutrition,

exercise, medication and blood glucose levels

• State the causes, signs and symptoms of hyperglycemia

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Survival Skills Continued

• Explain the proper treatment of hyperglycemia• State the causes, signs, and symptoms of

hypoglycemia• Explain proper treatment of hypoglycemia• State when to call healthcare provider• State where follow-up care will be provided

These objectives align with ADA approved curriculum

such as Life with Diabetes, Third Edition, A Series of Teaching Outlines by the University of Michigan Diabetes Research and Training

Center.

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What Do You Know About Your Patient?

• Location– Non-ICU– ICU

• Demographics– Age – LOS – Sex– Race/ethnicity– Payor

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What do you know about your patient?Continued

• Healthcare resources– Community resources– Family support

• Barriers to education and self-care– Mental status– General health and dexterity

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Admission

Discharge

Outpatients Follow-up

Lost to follow-up

Model Of Continuum of Diabetes Care

From Wheeler K Archives of Internal Medicine 2004;164:447-453

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Inpatient To Outpatient Transfer Of Diabetes Care: Why Is It Important?

• Ambulatory settings are the most common site of care

• Outpatient visits are the majority of physician contacts

• Patients who receive integrated outpatient diabetes care have better outcomes

• Regulation– National patient safety goal– Part of new Joint Commission’s requirement for

program certification in inpatient diabetes

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Appointment Adherence Correlates with Better Glycemic Outcomes

From Rhee MK et. al. Diabetes Educator 2005; 31:240-250.

Grady Diabetes Clinic, 1,560 Patients, 19912001

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Joint Commission StatementNational Patient Safety Goals

• Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions (2E)

• A complete list of the patient’s medications is communicated to the next provider of service (8B) – The complete list of medications is also provided to

the patient on discharge from the facility

• Plan for post-discharge education or self-management support (needed for disease specific certification)

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A Specific Hand-Off (Direct Referral)

at Discharge Is Key to Ensuring Follow-Up

0

2

4

6

8

10

New onsetdiabetes

Discharged oninsulin

Referral toDiabetes Clinic

Od

ds r

ati

o

658 patients discharged from Grady Memorial Hospital, 2001

From Wheeler K Archives of Internal Medicine 2004;164:447-453

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Self-Reported Barriers to Post-Discharge Follow-Up

0%

20%

40%

60%

Notransportation

Cannot affordvisit

No insurance Cannotremember

appointment

Afraid of losingjob

Other

303 inpatients at Grady Memorial Hospital, 2002

Most (95%) planned to have post-discharge follow-up, but…50% anticipated they would

have problems doing so.

Wheeler K et. al. Ethnicity and Disease, in press

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Variables Associated with Anticipating a Barrier To a

Post Discharge Follow-Up Visit

Odds ratio95% confidence

interval P value

Women vs. men 2.30 1.12-4.73 .024

Uninsured vs. insured 2.62 1.04-6.57 .040

Prior health care access trouble vs. no trouble

5.94 2.88-12.23 <.0001

Retired vs. employed 4.55 0.83-25.01 .081

College vs. high school 0.47 0.19-1.15 .098

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What You Can Do To Make Sure Your Patient

Is Ready for Discharge• Assess patient’s educational needs on

admission (What does the patient already know?)• Assess potential barriers to self-care• Assess potential barriers to follow-up• Determine follow-up (Who? Where? When?)• What will the therapy be at discharge?• Maximize level of glycemic control

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Utilize Existing Hospital Resources

• Inpatient Diabetes EducationYou must anticipate the need for education at

the beginning, not the end of the hospital stay

• Social Work

Your hospital most likely does not have a rapid-response

diabetes education team

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Discharge Documentation

• Diabetes/hyperglycemia

• Level of inpatient glycemic control

• Whether education received

• What the follow-up will be– Who– When– Where

• Discharge therapy

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Lecture Series Summary

• Identify the patient with hyperglycemia early in the hospitalization

• Treating hyperglycemia improves hospital outcomes

• There are systematic ways to estimate insulin requirements—avoid clinical inertia

• Your hospital’s policies and procedures relating to diabetes

• Make sure patient is ready for discharge