Releasing Time to Care. A journey towards evidence informed practice in the monitoring of blood glucose in the frail elderly in Long Term Care.

Transcription

1 Releasing Time to Care A journey towards evidence informed practice in the monitoring of blood glucose in the frail elderly in Long Term Care.

2 Objectives Describe the local context and approach to use of evidence to inform policy and practice change. Discuss early experiences and impact. To discuss spread plan.

3 Partners Project leaders: Kelli O Brien, Vice-President of Long Term Care and Rural Health, Western Health Heather Brown, Vice-President of Rural Health, Long Term Care, and Community Supports, Central Health Project teams at Western Health and Central Health, Newfoundland CADTH Liaison Sheila Tucker

4 From Here to There Introduction of Best Practice Guidelines Recognizing the Issue Opportunity for Improvement Contextualizing the Evidence Program Development

5 Estimated Number of Canadians with Diabetes *

6 Potential Savings for Canada * Public and private plans combined; type 1 and type 2 diabetic patients combined. Calculations based on 22% insulin users vs. 78% non-insulin users.

7 Opportunity Cost Represents the value of benefits foregone as the result of making a decision. Opportunity cost of funding test strips at current levels is substantial. In a health care system with finite resources, the resources spent on test strips are no longer available to fund other potentially beneficial interventions or services.

8 New Publications New Evidence International Diabetes Federation Clinical Guidelines Cochrane Review CDA 2013 Clinical Practice Guidelines

9 British Columbia s Test with Purpose Campaign

10 Nova Scotia s SMBG Decision Tool

11 Practice Change Pilot Project SK

12 CDA s SMBG Decision Tool

13 Choosing Wisely

14 Choosing Wisely

15 What Does CADTH Recommend?

16 Adults With Type 2 Diabetes Who Do Not Use Antidiabetes Drugs Routine use of blood glucose test strips for SMBG is not recommended for most adults with type 2 diabetes who do not use diabetes pharmacotherapy. Given a lack of evidence, women in this patient population who are considering a pregnancy may benefit from SMBG.

17 Adults With Type 2 Diabetes Using Oral Antidiabetes Drugs Routine use of blood glucose test strips for SMBG is not recommended for most adults with type 2 diabetes using oral antidiabetes drugs. Periodic testing may be beneficial for patients: using insulin secretagogues at risk of hypoglycemia experiencing acute illness undergoing changes in pharmacotherapy or significant changes in routine with poorly controlled or unstable glucose levels pregnant or planning a pregnancy

18 LTC Opportunity Cost

19 Rationale for this Initiative Aging population, Diabetes Prevalence Evidence of sub-optimal use of test strips in diabetes management New guidelines Role of blood glucose testing in diabetes management being reconsidered

20 Releasing Time to Care Goal: The project will support the achievement of best practice in the care of people with type 2 diabetes residing in long-term care facilities at Western Health and Central Health. Anticipated Benefits: Supports resident and family-centred care Improved assessment skills for care providers Less stress and pain for residents Improved utilization of resources More time and resources for improving the resident experience Monitoring foot, dental, and vision health, and A1C. Individualized care. Well-being, quality of life

21 Evidence & Information Used in the Projects Baseline utilization data (Central Health, Western Health) Informal cross-country scans (CADTH) CADTH Rapid Response Reports Management of Diabetes in the Long-Term Care Population: A Review of Guidelines (2013) Glucose Replacement Agents in Frail Elderly Patients with Type II Diabetes in Long-Term Care: Clinical and Cost- Effectiveness, Harms, and Guidelines (2015) Diabetic Diets for Frail Elderly Long-Term Care Residents with Type II Diabetes Mellitus: A Review of Guidelines (2015) Clinical experts - accredited webinar through CCHL-NL Canadian Diabetes Association Guidelines

22 Blood Glucose Monitoring in Long Term Care Practice Change Strategies: Policy change. Presentation & educational interventions for stakeholders Diabetes Care Committee; health professionals & other care providers; residents. Sharing of clinical practice tools and other evidence-based resources to support best practice. Evaluation Intervention activities and overall impact of the project on quality of care.

23 Policy Change Blood Glucose Monitoring Glycemic Control in the Frail Elderly

24 Education of Stakeholders Local Initiatives Regional Steering Committee Outreach to Physicians via LMACs Central Health Diabetes Retreat Provincial and National Initiatives: CCHL Webinar June provinces Pre and post tests of knowledge Evaluation of session- 78% participants agreed expectations met, informative and practical PULSE Newsletter Fall 2015 Blood glucose monitoring- what does the evidence say?

25 Education of Stakeholders Local Provider Education Sessions Spring 2015 Jointly across RHAs ~90% nursing staff participated Pre and post test of knowledge Improvements noted in all post test questions Range % point change 1-24%. Evaluation of sessions 93% -96% rated the session as good to very good, and as achieving the objectives set.

26 Clinical Practice Tools Developed/customized in consultation with project teams: Resident/family pamphlets Hypoglycemia standard kits Stop Hypoglycemia (new tool) Clinical practice guidance card Poster Pocket card

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28 Recognize the signs Stop Hypoglycemia

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31 Sample Hypoglycemia Kit

32 Evaluation Person-Centred The frequency of blood-glucose testing among persons living with non-insulin dependent diabetes in LTC is done as needed rather than routinely tested and is guided by the resident and/or family. Effective partnerships are demonstrated to achieve this goal. Efficiency of the Healthcare System A reduction in the cost of supplies for blood glucose testing and time spent performing blood glucose testing among persons living with non-insulin dependent diabetes in LTC. QUALITY DOMAINS Appropriateness of Care (Effectiveness) Knowledge is enhanced for use of best practices by care providers regarding the appropriate frequency of bloodglucose testing among persons living with non-insulin dependent diabetes in LTC. Safety Adverse outcomes are monitored relating to frequency of episodes of hypoglycemia among persons living with non-insulin dependent diabetes in LTC.

33 Releasing Time to Care: A Quality Improvement Project Spotlight on Western Health Time redirected by not inappropriately testing these residents: ~ nursing minutes per month 576 BGM initial month 117 BGM review month Focus on 33 residents from baseline Jan/14 to Nov/15 Policy change and education April Wow! That s 80% reduction for the cohort Projections for first year 15/16 with this cohort of 33 residents: ~504.8 nursing hours redirected ~ $ supply savings Monthly supply cost reduction by improving appropriateness of testing: ~$ Next Steps: Evidence guidelines for residents on insulin Standardized order sets

34 Improving Care for Residents with Diabetes Not on Insulin: A Quality Improvement Project Spotlight on Central Health (6 sites) Time redirected by not inappropriately testing these residents: ~946 nursing minutes per month 281 BGM Baseline (May 2015) 109 BGM Review Month (Nov 2015) May 2015: 5.1 BGM per resident Nov 2015: 1.8 BGM per resident No increase in hypoglycemic episodes Monthly supply cost reduction by improving appropriateness of testing: ~$92 61% reduction in blood glucose testing Projections for 15/16 based on baseline and 6 months of postdata (Jun-Nov 2015) : 174 nursing hours redirected $1014 supply savings Next Steps: Evidence guidelines for residents on insulin Standardized order sets

35 Sustainability Clinical Order Sets LTC Diabetes Management Order Set Residents Eating Meals LTC Diabetes Order Set for Hypoglycemia Orientation and e-learning Education

36 Spread Plan Residents using Insulin in LTC (Basal and Bolus) Implementation in ALC population in Acute care Use of Learnings to guide implementation in primary care

37 Questions?