Katherine J. Moran

Exploring the Cost and Clinical Outcomes of Integrating the Registered Nurse–Certified Diabetes Educator Into the Patient-Centered Medical Home

Purpose The purpose of this study was to implement and evaluate a care delivery model integrating the registered nurse–certified diabetes educator into the patient-centered medical home to assist in achieving positive clinical and cost outcomes in diabetes care. Methods A 1-group pretest-posttest research design was used. Patients were recruited from 2 patient-centered medical home designated/nominated primary care offices. Inclusion criteria were as follows: diagnosis of type 1 or type 2 diabetes, aged 18 to 80 years, A1C ≥ 8%, English speaking, and no diabetes education within 6 months. There were 34 participants (men, n = 22; women, n = 12) with a mean age of 53.24. The intervention incorporated an assessment, 4 patient-centered monthly group sessions, and 4 individual follow-up sessions. Study measures included program surveys, participation and satisfaction rates, Healthcare Effectiveness Data and Information Set attainment rates, and the following physiologic measures obtained from the medical record: A1C, fasting blood glucose, LDL, urine microalbumin, blood pressure, retinal eye exam, and body mass index. Cost-effectiveness measures included program costs, performance incentives, revenue, provider time saved, and patient health care utilization. Results Paired-samples t tests identified significant improvements in A1C, fasting blood glucose, and LDL. Patients and providers were highly satisfied with the program. Cost-benefit analysis revealed a net pretax program benefit. Conclusions Results of the study indicated that integrating the registered nurse–certified diabetes educator in the patient-centered medical home improves clinical outcomes and is cost-effective. Diabetes education and support are integral components of diabetes management.

Understanding the patient-centered medical home.

The patient-centered medical home (PCMH) is a team approach used to provide comprehensive care for patients in primary care settings that uses partnerships between patients and families, physicians, and other members of the healthcare team including home healthcare nurses. The goal of the PCMH model is to provide safe, high-quality, affordable, and accessible patient-centered care by promoting stronger relationships with patients, addressing care needs more comprehensively, and providing time to coordinate care across all sectors of the healthcare system. Home healthcare clinicians who have a deep understanding of the impact of community and family system interplay will have an important role in linking the home environment with the primary care based PCMH to assist patients to achieve optimal outcomes.

How to enjoy the holidays with diabetes.

The holiday season is a wonderful time of year, but for some, it can present challenges related to glucose control, especially when visiting friends and family. The good news is your patients do not need to sacrifice glucose control to partake in the festivities. The key is to plan ahead! During this time of year, your patients may be traveling to visit friends and family and are likely enjoying their favorite holiday treats. To help your patients maintain glucose control, it may help if you suggest a few of the following simple tips (American Diabetes Association, 2014; Centers for Disease Control and Prevention, 2013; Eating Well, 2014):

Diabetes and Nephropathy.

Kidney disease or nephropathy (albuminuria >30 mg/24 hours) is a potentially serious complication of diabetes, occurring in 20% to 40% of patients with diabetes. It is the leading cause of end-stage renal disease. According to the American Diabetes Association (ADA, 2015), screening for nephropathy should occur at least annually for all patients with type 2 diabetes by assessing urine albumin excretion by measuring the urine-albumin-tocreatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). Until recently, a UACR between 30–299 mg/24 hours was classified as microalbuminuria and a UACR >300 mg/24 hours was classified as macroalbuminuria. The ADA has now recommended a change in the terminology used to describe kidney disease, because albuminuria occurs on a continuum. Therefore, the old nomenclature has been replaced by the term “albuminuria” (UACR ≥30 mg/g). The UACR and eGFR tests are important for patients with diabetes because persistent increased UACR (30–299 mg/g) is a known marker for the development of kidney disease and cardiovascular disease risk. However, because variability in urinary albumin excretion is not uncommon, the ADA recommends that two of three specimens collected within a 3to 6-month period be abnormal (≥30 mg/g) before diagnosing a patient with microalbuminuria. Factors that may elevate urinary albumin excretion include exercise within 24 hours of the test, fever, infection, hyperglycemia, congestive heart failure, and marked hypertension (ADA, 2015). Another recent change in prevention of nephropathy relates to the use of an angiotensinconverting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). These antihypertensive medications used to be prescribed to patients with diabetes, even in the absence of a diagnosis of hypertension, in hopes of slowing down the onset or progression of nephropathy. However, the ADA (2015) now recommends that only those patients diagnosed with hypertension or an abnormal UACR be started on these drugs. There are a number of things that can be done to prevent the progression of the disease. Patients need to strive for optimum glucose and blood pressure control. Multiple studies have demonstrated that when patients are able to attain near normal glucose control the onset and/or progression of the disease can be delayed. For patients with diabetes and hypertension the ADA recommends treating to a goal of at least <140/90 mmHg (or lower, such as a systolic of <130 mmHg, if this can be achieved without undue burden). Second, regular monitoring of eGFR, creatinine, urinary albumin excretion, potassium, and other lab values is also recommended. Keep in mind, once the eGFR is <30 mL/min/1.73 m2 referral to a nephrologist is recommended (ADA, 2015). Another change in the ADA recommendations is related to protein intake for patients with diabetes and nephropathy. Reducing protein intake below the recommended daily allowance of 0.8 g/kg/day (based on ideal body weight) is not required. However, if the patient has nephropathy that is progressing, despite use of an ACE inhibitor or ARB and achieving glucose and blood pressure control, and the dietary protein intake is high, then protein limitation should be considered. Finally, while it is known that physical activity can increase urinary protein excretion there is no evidence that vigorous exercise increases the rate of progression of nephropathy; therefore, there is no need to restrict exercise in patients with diabetes and nephropathy (ADA, 2015).

Exercise and diabetes.

Effective diabetes management requires a balance of exercise, carbohydrate intake, and, in some cases, diabetes medications. Engaging in regular physical activity helps the body use insulin more effectively, which in turn helps to control blood glucose. In fact, some people are able to control their blood glucose with meal planning and exercise alone. Other benefits of regular physical activity may include: • Stress reduction • Weight loss • Increased flexibility • Stronger bones • Lower blood pressure and low-density lipoprotein cholesterol • Higher high-density lipoprotein cholesterol • Improved circulation • Reduced cardiovascular risks • Improved mood and overall sense of well-being

Type 2 Diabetes and Bariatric Surgery.

Bariatric surgery can be an effective therapy for weight loss in those who are obese. The American Diabetes Association (2015) reviewed the current available studies and recommendations regarding bariatric surgery and diabetes. For those with diabetes, an additional positive effect of bariatric surgery can be an improvement in blood sugar control. Seventy-two percent of patients achieve complete normalization of blood sugar 2 years following surgery. This compares to 16% of patients treated medically with lifestyle changes and medications. Characteristics that predict success include younger age, shorter duration of Type 2 diabetes, lower A1c, higher serum insulin levels, and nonuse of insulin. There are several types of bariatric surgery to understand (1) gastric bypass surgery, (2) laparoscopic gastric binding, and (3) sleeve gastrectomy. Gastric bypass surgery is a permanent change that shrinks the stomach and shortens the path that food takes as it travels through the small intestine. The number of calories absorbed is then limited. Laparoscopic gastric binding (lap-banding) consists of a belt wrapped around the stomach so the patient will feel full with less food. The banding can be adjusted or reversed. In sleeve gastrectomy, 80% of the stomach is removed. Sleeve gastrectomy has become the most popular weight loss surgery in the United States, accounting for 42.1% of the 179,000 procedures in the last year (“Remission rates,” 2014). Disadvantages of the procedures include cost and risk. Although the 30-day mortality rates have decreased to 0.28%, outcomes vary based on the procedure, experience of the surgeon, and the center. Safety improvements are primarily