Diabetes Management Early Detection and Management of Diabetic Neuropathy in a Clinical and Homecare Setting

The objective of this study is to examine early detection and management of diabetic neuropathy in a clinical and homecare setting and specifically through examination of articles published after 2002. The information from each source will be summarized listing the strengths and weaknesses of each article in separate paragraphs. As well, this work will utilize table or graphs to present the findings.

O'Reilly, Caryl Ann (2005) Managing the Care of Patients with Diabetes in the Home Care Setting, Diabetes Spectrum, July 2005. Vol. 18. No. 3. Retrieved from: http://spectrum.diabetesjournals.org/content/18/3/162.full

The work of O'Reilly (2005) reports that more patients than ever before are released earlier from hospitals and rehabilitation center and that those with diabetes are included in this trend. Diabetes is reported to be ranked second following congestive heart failure as the primary diagnosis at the time of entry into home care. The home health care nurse role is growing in importance with patients being discharged early from hospitals and rehabilitation center as this makes a requirement of nursing management at home that is more sophisticated in nature. In fact, as noted by O'Reilly "These nurses are often the only professional who has a complete overview of a patient's medical regimen and, therefore, responsibility for the coordination of care." (2005) In addition home health care nurses serve as the liaison between health care team member, family members, caregivers and patients. Home care agencies are the point of referral for acute episodes of care and these agencies use the Outcome and Assessment information Set (OASIS) for determining the needs of patients.

2. McLaughlin, Sue (2005) From Research to Practice/Diabetes Care in Special Settings: Meeting the Challenges: Diabetes Care in Special Settings Diabetes Spectrum July 2005 18:143-145. Retrieved from: http://www.vnsny.org/research/projects/1_implemetation.html

McLaughlin (2005) writes that the number of individuals in the home care setting receiving care for diabetes is growing rapidly. Proper management is stated to require that patients "understand the complexities of the disease, manage their diet, adhere to medication regimens and make other lifestyle changes." McLaughlin reports a study with the purpose of determining if an evidence-based quality improvement strategy would help elderly, homebound persons with diabetes in home care achieve better control of blood glucose levels; increase confidence in their ability to take medications as prescribed and manage their diabetes; and reduce their emergency department use." The study is reported to build on the design of the Implementation and Evaluation of Health Outcomes Management and Evaluation (HOME) Plans for Home Health Patients with Congestive Heart Failure's project and represents Phase II of this effort. Home health care nurses were randomly assigned to the intervention group (n=143) or the control group (n=126). Nurses in the intervention group received training on how to help patients improve their ability to take medications as prescribed. Use was a specialized assessment of patients' knowledge about diabetes medication management and provided patient education where necessary. Nurses also helped patients set goals for adherence to medication regimens, and patients received telephone support for 12 weeks to help them achieve these goals. Nurses in the control group provided usual care. All patients received care from the Visiting Nurse Service of New York." Findings in the study state that compared with patients that received usual care, patients in the intervention group "had a small but significant reduction in blood glucose levels. Patients in the intervention group reported more confidence in their medications as prescribed but they expressed more doubt about their ability to manage their diabetes in general." There was reported to be no significant difference in the use of the emergency room department between the two groups. The study concluded that an intervention that is evidence-based to improve adherence to diabetes medication regimens for patients who are elderly and homebound is one that is feasible and that can produce desired results.

3. Chavis, Selena (2010) No Better Time for Telehealth. For the Record, 1 Mar 2010. Vol. 22, No. 4. Retrieved from: http://www.fortherecordmag.com/archives/030310p20.shtml

The work of Chavis (2010) reports a study referred to as the DREME study in which 172 patients were diagnosed with diabetes. The participants ranged in age from 18 to 64 years of age and were chosen for the six-month study starting in April 2008. The remote monitoring process was comprised by a cell phone, a glucometer marketed by SymCare, and a Bluetooth cradle. The study is reported to have centered around "patient satisfaction with disease management services and changes in glycemic control." ( ) Outcomes reported by the study include that outcomes "…revealed significant improvements in both areas." ( ) Of the...

Compared with DM-Standard, the DM-Plus group reported greater satisfaction with their disease management experience in terms of believing program staff were helpful, articulate, better educated, and accessible. The results also showed the DM-Plus group improved self-care and had more stable glycemic control.
4. Isaac, Jennifer (nd) Remote Monitoring Reduces Hospitalizations, Improve Nurse Productivity. Edge Runners. Date Unknown. Retrieved from: http://www.aannet.org/files/public/PresbyterianHomeHealthcare_template.pdf

The work of Isaac reports a system in which the patients are referred through various sources, including a review of new hospital admissions that identifies patients with specific diagnoses. The study design is such that the telehealth RN visit the patient once or twice weekly, providing services similar to what a home visit nurse would provide -- checking vital signs, providing condition-related education and ensuring adequate self-care. Furthermore, the nurse conducted a review of the equipment to ensure it was working properly. Telehealth services are stated to generally continue for 6-8 weeks, monitoring services may continue for patients who are officially discharged from home care (and therefore no longer receive in home visits) but who could benefit from additional monitoring and education. Additionally, telehealth patients are asked to measure their vital signs, weight and oxygen saturation levels routinely. The telehealth software records these results and prompts patients to answer specific questions. Data was sent to a Web site for the telehealth RN for review and in the alert the RN of any matter needing attention. RN calls patients when alerted, or if patients do not enter information on a routine basis. RNs can perform additional assessments in response to the daily assessment data through a phone call.

Study findings show that the telehealth system has "…contributed to reduction in hospitalization rates among congestive heart failure patients, from 19% to 12.2% at the end of 2007. During the first quarter of 2008, the CHF hospitalization rate for telehealth patients dropped to 8%." ( ) In addition, the telehealth system has enhanced productivity; the patient load for telehealth RN is higher than that of visiting home health nurses. Telehealth RNs can conduct 6-8 visits per day, versus 5 for home health nurses, by eliminating travel time to remote areas. The system has enhanced RN productivity; the patient load for telehealth RNs is higher than that of visiting home health nurses. Telehealth RNs can conduct 6-8 visits per day, versus 5 for home health nurses, by eliminating travel time to remote areas. There is a savings of approximately $4,900-$8,000 is saved for each CHF hospitalization prevented, given an estimated 3- to 5-day length of stay. Surveys of participating patients indicate satisfaction rates of 96% with the telehealth service and Presbyterian Home Healthcare has a dedicated staff for the Telehealth Department of

2.3 staff nursing FTEs and a technician who deals with all installs and troubleshooting.

The work of Stachura and Dhasanshina (nd) reports that a study was conducted examining the benefits of technology for use in intensive blood glucose management and reports a randomized trials and meta-analyses conducted by Canadian researchers for determining where use of technologies can improve glycemic control or that of blood sugar control in Type 1 DM patients. The report states that the researchers used "wire telephone modem communication between patients' homes and a research computer. In a randomized trial of patients on an intensive insulin regimen that initially had failed to achieve glycemic control, the researchers found better overall glycemic control in patients receiving multiple daily insulin injections or continuous subcutaneous insulin infusion. Telehomecare enhanced adherence to self-monitoring, which is essential for achieving glycemic control. Meta-analyses showed that telehomecare was equivalent to intensive usual care (pooled HbA1c change from baseline: mean difference 0.2%, 95% Confidence Interval -- 0.2 to 0.6%)." (Stachura and Dhasanshina, nd) Video conferencing and data collection from glucose meters were install the homes of all patients.

Population

Intervention

Comparison

Outcomes

Nurses received training on how to help patients improve their ability to take medications as prescribed. Use was a specialized assessment of patients' knowledge about diabetes medication management and provided patient education where necessary. Nurses also helped patients set goals for adherence to medication regimens, and patients received telephone support for 12 weeks to help them achieve these goals. Nurses in the control group provided usual care. All patients received care from the Visiting Nurse Service of New York.

Small but significant reduction in blood glucose levels. Patients in the…