Patients with diabetes are at risk for other severe comorbidities which impacts the patient’s ability to successfully manage their diabetes, has negative outcomes associated with their diabetes, and is fiscally taxing to individuals, families and the health care system. Macrovascular complications include cerebrovascular disease, coronary artery disease, heart failure, myocardial infarction, and stroke. Microvascular complications include nephropathy, retinopathy, and neuropathy. Comorbid conditions of diabetes include hypertension, dyslipidemia, obesity, nonalcoholic fatty liver disease, obstructive sleep apnea, cancer, depression and anxiety disorders, and erectile dysfunction.
North Carolina has one of the highest diabetes rates in the country, with Eastern North Carolina, having significantly higher rates at 11.1 %, compared to the national rate of 9.6 %. Among African Americans the rate in Eastern North Carolina is 15.3%, compared to 9.9% of whites in that region. Out of the 44 counties in Eastern North Carolina 86% have lower than average life expectancies. Compared to the national average residents of North Carolina with diabetes are more likely to be obese/overweight, have less physical activity, eat less fruits and vegetables, and are likely to also have hypertension and high cholesterol.
From January to September 2018, a Clinical Nurse Specialist (CNS) consulted with 50 patients newly diagnosed with diabetes, assisting with the patient's plan of care. This CNS is employed by an academic medical center in Eastern North Carolina, a rural area of the state. The CNS worked with the treatment team, which included the patient’s Primary Nurse, providers, dietitians, case managers, and the patients and families. If the patient had no insurance or was underinsured patients were placed on lower cost insulins and/or oral medications lessening the financial burden of prescribed medications, assising the patients in issues related to compliance. Discharged patients received a brief educational handout, along with timely follow-up appointments with a provider and diabetes educator. Meeting with a diabetes educator after discharge allows the patient to become familiar with diabetes self-management and the survival skills to ensure safely caring for the chronic illness of diabetes. None of these patients were readmitted, decreasing the financial and social burden of diabetes.
Brief, targeted education was provided by the Primary Nurse and the CNS. The Primary Nurse was taught to give the patient a one page handout which included survival skills necessary to ensure a safe transition to home. Also, on this document were who to call for help (Primary Provider) and the date and time of the patient’s follow up appointment with a Provider. Patients were also given the contact information for a diabetes educator if one was not at their provider’s location. Follow up appointments were made by the Primary Team, Case Management, and/or the CNS. Most appointment were made within one week to ten days of discharge.
The survival skills listed on this document include medications prescribed, when to take and/or hold these medications, how often to check a finger stick blood glucose level, along with targets of these levels. Patients were also taught hypoglycemia and hyperglycemia, including signs and symptoms of both, how to treat, and when to call a provider.
Newly diagnosed patients are often placed on insulin in this hospital because often they do not have the financial means to see a Primary Physician except for illness and when they are admitted their Hemoglobin A1C’s are elevated, calling for the Provider to prescribe insulin. To ensure patients understand how to inject insulin (and how to use a glucometer) the Primary Nurse and CNS use the teach-back method, in which patients are asked to demonstrate back the skills they learned. Also, when hospitalized the Primary Nurse will have patients draw up and inject their prescribed insulin.
Patients and families who live in rural populations are negatively impacted when diagnosed with diabetes. In rural populations there are higher morbidity and mortality rates, with African Americans the highest of these rates. Rural population have lower incomes, along with lower education which leads to having less money and decreased access to healthcare, especially minority populations.
Diabetes is costly to patients, the healthcare system, along with local, state, and federal governments. In the United Stated in 2017 diabetes costs 327 billion with 237 billion being direct costs and 90 billion reduced productivity. The annual per capital healthcare is 2.3 times higher when someone is diagnosed with diabetes, with a large portion due to the comorbidities associated with diabetes. Other costs which are increased include: 69.7 million for higher inpatient services, 34.6 billion for higher medications and supplies, 30 billion for more office visits to provider and other health care providers, 90 billion due to lost work absenteeism, and medications associated with diabetes 43% of the healthcare burden.
Successful diabetes management is necessary for patients diagnosed with diabetes to help decrease comorbidities associated with diabetes, decease increased morbidity and mortality associated with diabetes, and decrease financial and social strains for patients and the healthcare system.
Targeted brief education, with necessary provider and educator follow up, allows a patient newly diagnosed with diabetes to begin a path to successfully manage the chronic disease of diabetes.