5 Strategies for Managing Insulin for Short-Stay LTC Residents
Helen Halchuk, RPH, Director of Client Services at SRX
November 2, 2020
Managing diabetes in long-term care facilities is a prevailing problem.
“Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost.”
Managing diabetes in long-term care facilities is a prevailing problem. Of the over 1 million LTC residents in the country, estimates say 25-34 percent of this population has diabetes and is predicted only to grow. On top of that, many of these diabetic residents are more likely to have additional health problems connected with the disease. Combined with the fact that the elderly, in general, have multiple comorbidities and many are not well educated in their diabetes management, caring for seniors and PWD is an enormously complicated issue.
I’d like to focus on one specific issue among this population that stands out—the continued difficulty of managing insulin during short stays. Here’s how I’ve seen this problem play out.
A Typical Scenario
- A 75-year-old with type 2 diabetes, on an oral agent plus long-acting insulin, gets admitted to the hospital.
- To better manage the fluctuations of her blood sugars, the oral agent and insulin are changed to sliding scale insulin (SSI) based on blood sugar readings taken four times a day.
- On transfer to the post acute facility, the insulin regime started in the hospital is continued.
At this point, the patient has had multiple medications, and a new or complex regimen might be too difficult for home management. When patients get discharged, how are we to expect them to keep their diabetes under control and adhere to a program?
Let’s step back and look at how challenges in the care continuum can compound this issue.
The Problem: Transitional Care
“Transitions from the hospital or home to LTC, transitions across care settings in LTC facilities, changes in providers, and discharges to the community setting are high-risk times for patients with diabetes.” —American Diabetes Association
The American Medical Directors Association defines transitional care as “actions that ensure coordination and continuity of care and are based on a comprehensive care plan.”
We know that doesn’t always happen. There isn’t a roadmap or care document that accompanies a patient from one care setting to the next, making transitional care challenging. The ADA claims discharge summaries often lack information such as diagnostic test results, treatment or hospital course, discharge medications, test results pending at discharge, patient or family education, and follow up plans.
In addition, the following scenarios contribute to the complexity of care, putting residents’ health at risk.
- Stress-induced erratic blood sugar levels
- When the resident moves from the hospital to the post acute care unit, she may become more stressed due to new arrangements. Stress raises blood sugar levels, and therefore insulin may be increased. Controlling these erratic levels is very labor-intensive for the nurses as they need to assess the resident’s BS by finger sticks four times a day. Based on those BS readings, insulin is administered.
- Higher risk of serious hypoglycemic event
- Elderly residents are at a higher risk of the severe consequences of hypoglycemia. Their risk escalates if they don’t eat because they might not like the food at the home. Physical therapy reduces BS levels, and this can also lead to hypoglycemia.
Solutions to Successfully Transitioning Patients & Managing Insulin
“A successful transition is a process whereby senders and receivers validate the transfer, accept the information, clarify any discrepancies, and act on the information to ensure a smooth and safe transition of care.” —American Medical Directors Association, Diabetes Management in the Long-Term Care Setting Clinical Practice Guideline
Many challenges build on each other as patients move through the continuum of care. Let’s go back to our 75-year-old who has transitioned from hospital to short stay. How do we give her the tools to succeed with her medication and insulin management at home? Below are five solutions that could provide her and other patients who leave short-stay facilities with a manageable medicine regimen.
- Switching to B-BI therapy
- A study published by JAMBA examining SSI versus basal-bolus insulin therapy in LTC residents with type 2 diabetes determined that switching to B-BI therapy appears to be effective, safe, and feasible.
- Combining a GLP-1 receptor agonist and basal insulin
- According to a paper authored by Jennifer M. Trujillo, clinical studies have shown improved glycemic control and low risk of hypoglycemia with this combination.
- Educate the resident and family during the post-acute stay about the benefits that a healthy lifestyle can have on the resident’s short-term outcomes, including:
- Physical activity and exercise (depending on age/ability)
- The ADA recommends allowing liberal diet plans and minimizing restrictive therapeutic diets to avoid dehydration and unintentional weight loss.
- Educate the resident and family about the diabetes medications that she will be discharged home on. The communication should include the signs, symptoms, and treatment of hypoglycemia.
- On discharge, refer the resident to a home health agency and certified diabetes nurse educator for ongoing customized education.
A Simple Mission
We need to remember that managing diabetes and insulin for those in LTC facilities should be about comfort and quality of life, not prevention. As healthcare professionals, our role should always be to provide the patient and their loved ones with the best practices and medications throughout the care continuum by striving to be more consistent and communicative during transitional phases.