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Posts tagged ‘American Diabetic Association’

Care for the (whole) Person with Diabetes


A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.

Recommendations[1]

  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

Foot Assessment Tutorial


It is not my style to knock the advice given by the American Diabetic Association, Podiatrists, the Lower Extremity Amputation Prevention Program or all of those other so-called experts who teach foot exams.  I certainly buy into their position that assessing feet is important for so many reasons but I find that their instructions are incomplete.  In response, Haydel Consulting Services, LLC has stepped up to the plate to provide you with the missing pieces for a complete foot exam.  Pay close attention.  The skills you learn could save a limb or a life.

  1. Start with a foot encased in a shoe and sock.  Take a look at the shoe to make sure it is appropriate for the patient and fits well.  High heels, flip flops and all the other really cool kinds of shoes are not appropriate for many of our elderly patients.  No matter how ugly the shoe is, do not criticize the patient’s choice of footwear if the shoes meet the above criteria.
  2. Untie the shoe.  This may add some time to your visit but it will definitely make it easier to complete the following steps.
  3. Gently ease the shoe off the foot.  Do not pull, tug or otherwise force the shoe off to prevent the foot from coming off with the shoe.
  4. Inch the sock down from the top towards the toes until the entire foot is visible.  DO NOT ATTEMPT STEP 4 UNTIL STEPS 1 – 3 ARE COMPLETE.
  5. Attentively assess the foot according to the incomplete guidelines published by above referenced agencies.  Notice how the nurse in this photo (Susie Soskin, RN) is at eye level with the foot.  If you cannot get down to eye level, find someone who can or get the patient to lay down in the bed.  If your knees are too old to bend down then chances are your vision is not good enough to assess feet from a distance.
  6. These are perfect feet.  I know this because they belong to my son.  I have bought hundreds of shoes for these size elevens.  At the cash register, I have often been a bit overwhelmed at the cost of keeping him in shoes.  After taking care of a few amputees, I am honored to have had the privilege to buy full pairs of shoes for him.  I hope when I am dead and gone, he still has to pay for a full pair.

A high resolution copy of the above tutorial is available by clicking here.  Please feel free to print it, share it or ignore it.  And yes, I know the vast majority of us do take shoes and socks off every visit and look at diabetic feet.  This is good but diabetics are not the only patients who benefit from foot assessments.  Patients with heart failure or take diuretics will show signs of fluid build up in their feet, compromised circulation from cardiovascular or other disease can result in discoloration or stasis ulcers and injuries to the feet can be overlooked by any patient with loss of sensation or callused skin.

So, if this helps you to remember, all is well.  If you don’t need reminding, kudos to you.  If you think that one of your nurses or coworkers is not taking the time to do a complete foot assessment, draw a happy face on the bottom of the foot and see what shows  up in the documentation:)

As always, questions and comments are welcome below or via email.  As so on…..

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