Accurate provider communication, medication reconciliation, patient and caregiver involvement and diabetes education can improve home recovery of patients with diabetes, according to nursing experts.
Even in ideal situations, transition from the hospital to home may be difficult, but effective communication is a great start for successful continuity and coordination of care, said Jacqueline LaManna, PhD, ANP-BC, BC-ADM, CDE, assistant professor at the University of Central Florida, Orlando.
“What we’re seeing now … is the primary care provider, who knows the patient, is not the one directing the hospital care. So that becomes an issue when they return back to the community,” said LaManna, who gave a presentation on “Optimizing home recovery transitions of patients with diabetes: Multimorbidity, medication and more” at the American Diabetes Association’s 30th annual clinical conference in May.
Preparing patients and the caregiver for the next level of care, especially with their prescriptions, also is essential for successful care transition.
“There’s a high risk for medication error when they return home,” LaManna said. “That usually happens in the first 24 hours of discharge.”
The likelihood of error is higher in patients prescribed seven or more medications at discharge, she said. And a significant percentage of patients will have a change in their diabetes regimen at discharge, which is also a risk factor for readmission.
Medication reconciliation is one of the biggest challenges patients face when being discharged from a facility, said Debra Hershon, RN, executive director for Distinguished Care Options, a private duty home care agency in Natick, Mass., and a care transitions coordinator for Natick Visiting Nurse Association.
Upon discharge, a list of inpatient medications is provided, but patients may have other medications at home they were taking prior to their hospitalization. Once they return home, over-the-counter medications, vitamins and supplements, which they may have not taken while hospitalized, can cause “major confusion as to what medications and supplements they should — and should not — take,” Hershon said. “It is vital for a home care nurse to reconcile these meds with doctors, the pharmacy, patients and caregivers so that they are taking the proper meds.”
Not only is a medication chart a helpful tool; but it also is important that the patient understands why he is taking each medication. “Too often, patients take a long list of medications but have no idea why,” she said.
Health literacy is key
Diabetes education is essential to help patients and caregivers make sound decisions as well as learn the signs and symptoms of health problems, nurses said. This health literacy should continue throughout the patient’s stay. Shorter informational sessions can improve retention, nurses said.
“The most important thing to improve care transition is education prior to discharge,” Hershon said. “For older adults, having a caregiver present during the teaching portion of the transition is vital to their success at home.”
Diabetes educators need to know what the patient does at home, LaManna said. Questions include: How do they monitor their blood sugar? Can they afford the medications?
Successful home recovery also requires self-management opportunities for patients during their hospital stay, including monitoring their blood sugar targets, LaManna said. “Many patients become very frustrated with blood glucose control after discharge because blood sugar goes up when they are ill, and they need to understand the whys of this and how to manage it.”
Before discharge, it is important to identify the factors that can interfere with the patient’s self-care such as blindness and hearing and mental deficits. Examine their psychosocial barriers. Do they live alone? Are they depressed or have other mental health issues? Can they read and understand and act on health information? Can they use and measure numbers?
Successful post-op care requires changes in thinking and daily living practices, said E. Lynn Fraley, MN, DPh, RN, a speaker, educator and consultant based in San Francisco. Healthy meal-planning skills and knowledge are essential, she said.
“It is critical for people with diabetes to accept that their best medicine is their food … and they probably need to be educated or re-educated about nutrients,” said Fraley, adding emotional eating also can be problematic.
“Whether they come to terms with this through Weight Watchers or Overeaters Anonymous, reading any number of books or reading online blogs, there is no other path to healing than eating foods that nourish and heal,” Fraley said. “Watching for signs of gangrene or charting vision loss are hardly proactive plans to manage a serious disease with a high mortality rate.”
Diabetes adds complexity to the post-discharge experience, LaManna said. Patients must integrate knowledge and skills to manage their health at home. They must be aware of how to deal with common issues encountered at home such as pain management, nausea and activity limitations. Assess their understanding by using teach-back methods, she said.
Following up with a phone call within two days after discharge is important too, according to LaManna. It increases patient satisfaction and decreases emergency room visits and readmissions, she said.