Predischarge preparation for diabetes management lowers recidivism

ORLANDO – Older hospitalized patients with diabetes who felt unprepared for discharge or who had coping difficulties after discharge had a significantly increased risk of readmission within 30 days in a prospective mixed-methods study.

The findings have important implications for diabetes educators, according to Jacqueline LaManna, Ph.D., of the University of Central Florida, Orlando.

Of 96 patients with a mean age of 75 years who were included in the qualitative and quantitative study, 30 experienced an event of recidivism, defined as an unplanned provider or emergency department visit, and 16 of those were readmitted within 30 days, Dr. LaManna reported at the annual meeting of the American Association of Diabetes Educators.

Perceived readiness for discharge was lower in those who experienced an event of 30-day recidivism. Other factors associated with 30-day recidivism included difficulty managing medications, difficulty controlling or managing diabetes, and difficulty managing other chronic health problems. All these associations were statistically significant and were interrelated, Dr. LaManna said.

Difficulty managing medications after discharge was also associated with lower perceptions of transition quality.

Scores on the 15-item Care Transition Measure (CTM-15) – a measure of perceived transition quality – were positively correlated, with high statistical significance, with readiness for discharge, quality of discharge content provided, and skill of the nurse in delivering discharge content. Greater reported difficulty in the early transition period was associated with lower CTM-15 scores.

Scores on the Post-Discharge Coping Difficulties Scale (PDCDS) were higher in subjects who reported unmet information needs, those who experienced 30-day recidivism, and those who experienced problems managing medications, controlling diabetes, and managing other chronic illness during the early and intermediate transition periods.

A model including three factors that were significant predictors of recidivism – 7-day PDCDS score, 30-day PDCDS score, and difficulty managing chronic illness – correctly classified 78% of cases of event recidivism within 30 days, Dr. LaManna said.

Factors that were not associated with recidivism – either in the early (within 7 days) or intermediate (within 30 days) stage after discharge – included age and sex, chronic disease dyad pattern, diabetes-related health status variables, use of hospitalist services, length of stay, quality of discharge teaching, availability of an in-home family care provider, and use of home health services.

Several major themes, with implications for diabetes educators, emerged from the following findings, Dr. LaManna said:

• The daily stuff is difficult. Study participants commonly reported having difficulty with personal care and household tasks, walking and mobility, transportation, and obtaining supplies and medicine.

• Engineering care at home is complex. Many participants reported feeling that they "come last," because they are the caretakers for grandchildren, elderly spouses, and/or elderly parents. Managing things on their own is also difficult, and while they were diligent in mobilizing resources for support in an effort to remain independent, support systems are very fragile. Also, the hospital-to-home transition is difficult on families and this increases patient stress.

• Life is stressful. Many subjects complained about having to deal with too many outside influences with respect to their care and decisions, and many struggled with grief and depression and/or anxiety and frustration.

• Managing numerous complex health problems is onerous. Maintaining diabetes control was difficult for many patients, as was managing other chronic health problems. Trying to keep track of multiple medications was a particular challenge, and many subjects said they needed more information to help them with self-management.

Of note, many of these factors were at least as much of an issue at 30 days as they were at 7 days. For example, personal care remained an issue over time, with an equal proportion (56%) of patients reporting have such difficulties at 7 and 30 days, respectively. Further, the overall percentage of patients reporting difficulty managing multiple health problems increased from 52% to 78%, and the percentage having difficulty controlling their diabetes, in particular, increased from 18% to 29%.

This latter finding is particularly concerning given that the cut-off for most case management programs is 30 days.

"They are setting up for the next [recidivism] event," Dr. La Manna said.

The findings show that the home recovery transition is dynamic, and that the needs of older adults and family caregivers change.

Adults with cognitive impairment were not included in this study, so the findings represent somewhat of a "best-case scenario."

Thus, the findings suggest that even in "ideal" cases, the transition may be difficult, Dr. LaManna said, noting that the obstacles patients face are numerous.

"We need to be considering, as diabetes educators, what’s going on – not just with diabetes, but with other chronic health conditions. Multimorbidity is a really important thing," Dr. LaManna said.

The findings also suggest a need for inclusion of discharge readiness assessment into transitional care practices to improve predischarge identification of patients at risk for recidivism, and a need for sequential postdischarge follow-up for a longer period of time.

In the ambulatory setting, it would be useful to include PDCDS assessment, which includes only 10 simple questions.

"It might help you to identify somebody who’s struggling at home who could benefit from referral right then and there – at least warranting some follow-up. That could absolutely very easily be done in ambulatory setting," she said, noting that inclusion of a family stress assessment into transition planning is also important.

The findings suggest that diabetes educators have the potential to positively affect the transition experiences of hospitalized older adults and their family caregivers (the hospital from which patients for this study were recruited had no diabetes educators on staff).

Dr. LaManna reported having no disclosures.

ORLANDO – Older hospitalized patients with diabetes who felt unprepared for discharge or who had coping difficulties after discharge had a significantly increased risk of readmission within 30 days in a prospective mixed-methods study.

The findings have important implications for diabetes educators, according to Jacqueline LaManna, Ph.D., of the University of Central Florida, Orlando.

Of 96 patients with a mean age of 75 years who were included in the qualitative and quantitative study, 30 experienced an event of recidivism, defined as an unplanned provider or emergency department visit, and 16 of those were readmitted within 30 days, Dr. LaManna reported at the annual meeting of the American Association of Diabetes Educators.

Perceived readiness for discharge was lower in those who experienced an event of 30-day recidivism. Other factors associated with 30-day recidivism included difficulty managing medications, difficulty controlling or managing diabetes, and difficulty managing other chronic health problems. All these associations were statistically significant and were interrelated, Dr. LaManna said.

Difficulty managing medications after discharge was also associated with lower perceptions of transition quality.

Scores on the 15-item Care Transition Measure (CTM-15) – a measure of perceived transition quality – were positively correlated, with high statistical significance, with readiness for discharge, quality of discharge content provided, and skill of the nurse in delivering discharge content. Greater reported difficulty in the early transition period was associated with lower CTM-15 scores.

Scores on the Post-Discharge Coping Difficulties Scale (PDCDS) were higher in subjects who reported unmet information needs, those who experienced 30-day recidivism, and those who experienced problems managing medications, controlling diabetes, and managing other chronic illness during the early and intermediate transition periods.

A model including three factors that were significant predictors of recidivism – 7-day PDCDS score, 30-day PDCDS score, and difficulty managing chronic illness – correctly classified 78% of cases of event recidivism within 30 days, Dr. LaManna said.

Factors that were not associated with recidivism – either in the early (within 7 days) or intermediate (within 30 days) stage after discharge – included age and sex, chronic disease dyad pattern, diabetes-related health status variables, use of hospitalist services, length of stay, quality of discharge teaching, availability of an in-home family care provider, and use of home health services.

Several major themes, with implications for diabetes educators, emerged from the following findings, Dr. LaManna said:

• The daily stuff is difficult. Study participants commonly reported having difficulty with personal care and household tasks, walking and mobility, transportation, and obtaining supplies and medicine.

• Engineering care at home is complex. Many participants reported feeling that they "come last," because they are the caretakers for grandchildren, elderly spouses, and/or elderly parents. Managing things on their own is also difficult, and while they were diligent in mobilizing resources for support in an effort to remain independent, support systems are very fragile. Also, the hospital-to-home transition is difficult on families and this increases patient stress.

• Life is stressful. Many subjects complained about having to deal with too many outside influences with respect to their care and decisions, and many struggled with grief and depression and/or anxiety and frustration.

• Managing numerous complex health problems is onerous. Maintaining diabetes control was difficult for many patients, as was managing other chronic health problems. Trying to keep track of multiple medications was a particular challenge, and many subjects said they needed more information to help them with self-management.

Of note, many of these factors were at least as much of an issue at 30 days as they were at 7 days. For example, personal care remained an issue over time, with an equal proportion (56%) of patients reporting have such difficulties at 7 and 30 days, respectively. Further, the overall percentage of patients reporting difficulty managing multiple health problems increased from 52% to 78%, and the percentage having difficulty controlling their diabetes, in particular, increased from 18% to 29%.

This latter finding is particularly concerning given that the cut-off for most case management programs is 30 days.

"They are setting up for the next [recidivism] event," Dr. La Manna said.

The findings show that the home recovery transition is dynamic, and that the needs of older adults and family caregivers change.

Adults with cognitive impairment were not included in this study, so the findings represent somewhat of a "best-case scenario."

Thus, the findings suggest that even in "ideal" cases, the transition may be difficult, Dr. LaManna said, noting that the obstacles patients face are numerous.

"We need to be considering, as diabetes educators, what’s going on – not just with diabetes, but with other chronic health conditions. Multimorbidity is a really important thing," Dr. LaManna said.

The findings also suggest a need for inclusion of discharge readiness assessment into transitional care practices to improve predischarge identification of patients at risk for recidivism, and a need for sequential postdischarge follow-up for a longer period of time.

In the ambulatory setting, it would be useful to include PDCDS assessment, which includes only 10 simple questions.

"It might help you to identify somebody who’s struggling at home who could benefit from referral right then and there – at least warranting some follow-up. That could absolutely very easily be done in ambulatory setting," she said, noting that inclusion of a family stress assessment into transition planning is also important.

The findings suggest that diabetes educators have the potential to positively affect the transition experiences of hospitalized older adults and their family caregivers (the hospital from which patients for this study were recruited had no diabetes educators on staff).

Dr. LaManna reported having no disclosures.

ORLANDO – Older hospitalized patients with diabetes who felt unprepared for discharge or who had coping difficulties after discharge had a significantly increased risk of readmission within 30 days in a prospective mixed-methods study.

The findings have important implications for diabetes educators, according to Jacqueline LaManna, Ph.D., of the University of Central Florida, Orlando.

Of 96 patients with a mean age of 75 years who were included in the qualitative and quantitative study, 30 experienced an event of recidivism, defined as an unplanned provider or emergency department visit, and 16 of those were readmitted within 30 days, Dr. LaManna reported at the annual meeting of the American Association of Diabetes Educators.

Perceived readiness for discharge was lower in those who experienced an event of 30-day recidivism. Other factors associated with 30-day recidivism included difficulty managing medications, difficulty controlling or managing diabetes, and difficulty managing other chronic health problems. All these associations were statistically significant and were interrelated, Dr. LaManna said.

Difficulty managing medications after discharge was also associated with lower perceptions of transition quality.

Scores on the 15-item Care Transition Measure (CTM-15) – a measure of perceived transition quality – were positively correlated, with high statistical significance, with readiness for discharge, quality of discharge content provided, and skill of the nurse in delivering discharge content. Greater reported difficulty in the early transition period was associated with lower CTM-15 scores.

Scores on the Post-Discharge Coping Difficulties Scale (PDCDS) were higher in subjects who reported unmet information needs, those who experienced 30-day recidivism, and those who experienced problems managing medications, controlling diabetes, and managing other chronic illness during the early and intermediate transition periods.

A model including three factors that were significant predictors of recidivism – 7-day PDCDS score, 30-day PDCDS score, and difficulty managing chronic illness – correctly classified 78% of cases of event recidivism within 30 days, Dr. LaManna said.

Factors that were not associated with recidivism – either in the early (within 7 days) or intermediate (within 30 days) stage after discharge – included age and sex, chronic disease dyad pattern, diabetes-related health status variables, use of hospitalist services, length of stay, quality of discharge teaching, availability of an in-home family care provider, and use of home health services.

Several major themes, with implications for diabetes educators, emerged from the following findings, Dr. LaManna said:

• The daily stuff is difficult. Study participants commonly reported having difficulty with personal care and household tasks, walking and mobility, transportation, and obtaining supplies and medicine.

• Engineering care at home is complex. Many participants reported feeling that they "come last," because they are the caretakers for grandchildren, elderly spouses, and/or elderly parents. Managing things on their own is also difficult, and while they were diligent in mobilizing resources for support in an effort to remain independent, support systems are very fragile. Also, the hospital-to-home transition is difficult on families and this increases patient stress.

• Life is stressful. Many subjects complained about having to deal with too many outside influences with respect to their care and decisions, and many struggled with grief and depression and/or anxiety and frustration.

• Managing numerous complex health problems is onerous. Maintaining diabetes control was difficult for many patients, as was managing other chronic health problems. Trying to keep track of multiple medications was a particular challenge, and many subjects said they needed more information to help them with self-management.

Of note, many of these factors were at least as much of an issue at 30 days as they were at 7 days. For example, personal care remained an issue over time, with an equal proportion (56%) of patients reporting have such difficulties at 7 and 30 days, respectively. Further, the overall percentage of patients reporting difficulty managing multiple health problems increased from 52% to 78%, and the percentage having difficulty controlling their diabetes, in particular, increased from 18% to 29%.

This latter finding is particularly concerning given that the cut-off for most case management programs is 30 days.

"They are setting up for the next [recidivism] event," Dr. La Manna said.

The findings show that the home recovery transition is dynamic, and that the needs of older adults and family caregivers change.

Adults with cognitive impairment were not included in this study, so the findings represent somewhat of a "best-case scenario."

Thus, the findings suggest that even in "ideal" cases, the transition may be difficult, Dr. LaManna said, noting that the obstacles patients face are numerous.

"We need to be considering, as diabetes educators, what’s going on – not just with diabetes, but with other chronic health conditions. Multimorbidity is a really important thing," Dr. LaManna said.

The findings also suggest a need for inclusion of discharge readiness assessment into transitional care practices to improve predischarge identification of patients at risk for recidivism, and a need for sequential postdischarge follow-up for a longer period of time.

In the ambulatory setting, it would be useful to include PDCDS assessment, which includes only 10 simple questions.

"It might help you to identify somebody who’s struggling at home who could benefit from referral right then and there – at least warranting some follow-up. That could absolutely very easily be done in ambulatory setting," she said, noting that inclusion of a family stress assessment into transition planning is also important.

The findings suggest that diabetes educators have the potential to positively affect the transition experiences of hospitalized older adults and their family caregivers (the hospital from which patients for this study were recruited had no diabetes educators on staff).

Dr. LaManna reported having no disclosures.