Diabetes is not an uncommon diagnosis in older adults; however, this diagnosis can be linked to higher costs and greater disease burden. Rehabilitation and skilled nursing facilities (SNF’s) are now able to take advantage of these increased costs through the Patient-Driven Payment Model (PDPM), under Non-Therapy Ancillary (NTA) comorbidities, yielding two points for an active diabetes mellitus diagnosis. Understanding what may lead to blood glucose level variances and how to manage levels within care settings allows staff to provide the education and assistance residents need to meet their individualized goals for treatment, nutritional needs, and overall plan of care.
What impacts someone with diabetes in these settings?
- Elevated blood glucose levels may be related to acute illness (including infections), stress, drug interactions, diagnosis such as gastroparesis and wound healing, increased insulin resistance
- Current medication regimens, that may be based off hospital orders or previous recommendations, need to be reviewed with the continuance of care, as sliding scale insulin (SSI) is no longer advised by the American Diabetes Association (ADA) for primary treatment in the long-term care (LTC) setting
- Lower blood glucose levels may be related to recent hospitalization, advanced age, polypharmacy, impaired renal function, slowed intestinal absorption and hormonal regulation, varied nutritional intakes
- Previous barriers prior to admission including denatured insulin, lack of funds, food or medicine, lack of time for proper education or meal preparation, knowledge deficits
What can we do to help our residents be successful in their diabetes management?
- Assist in managing hypoglycemia and hyperglycemia through blood glucose monitoring, medication management, scheduled meal and snacks. Additional monitoring through lab work may be needed, such as B12 levels with the use of Metformin, and those taking sulfonylureas should be closely monitored as residents with poor appetites are more susceptible to hypoglycemia
- Individual diets. Many SNFs and rehab centers have moved to more a more liberalized diet approach (regular diet, low or no concentrated sweets diet) verses more restrictive diets, carbohydrate counting/restricted diet or specific diet orders. This can allow residents to make choices that may be more relatable to when they are at home, as well as allowing them to utilize the education they have received for healthful meal choices, and increased oral intakes at meals
- The ADA does note diets such as low/no concentrated sweets or sugar diets are ineffective for blood glucose control and should not be recommended
- If nutrition therapy is appropriate, meal planning should be individualized on a case by case basis, with some general guidelines to follow, including:
- Three to five servings of carbohydrates per meal
- One serving is equal to approximately 15 grams of carbohydrates
- Carbohydrate sources include: grains, breads, pastas, rice, beans/legumes, starchy vegetables, fruits, milk/dairy products, sweets
- One to two servings of carbohydrates per snack
- Make at least half of your grains whole grains
- Whole grains contain more fiber than refined grains
- Fiber helps to slow down the absorption, which in turn helps to stabilize blood sugars
- Eat four to six ounces of protein (chicken, fish, lean meat, low-fat dairy, soy, etc.)
- Include healthy fats: olive oil, avocado, nuts/seeds
- Limit saturated fat, which is found in butter, cream, and high-fat meats
- Avoid/limit trans fats, which are found in many processed foods, baked goods, and may be labeled as “partially hydrogenated oil”
- Three to five servings of carbohydrates per meal
- Consider overall plan of care and resident needs
- Recommendations per the ADA include: older adults in LTC who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.5%), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1C <8.0–8.5%)
- Community-dwelling residents receiving short-term rehabilitation should adhere to more glycemic control to aid in recovery, avoidance of infections, and wound healing
- Utilizing guidance from your Registered Dietitian, clients returning home or more independent living situations, resources can be provided to increase success, such as the Diabetes Food Hub from the ADA and personalized handouts
Understanding how and why diabetes impacts residents can lead to confidence in caring for and providing education to residents. With individualized plans of care and approaches to resident health, SNFs and post-acute rehabilitation settings can greatly improve resident outcomes and quality of life, whether remaining in the LTC setting, or returning home.
American Diabetes Association. 12. Older adults: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42(Suppl. 1):S139–S147. doi:10.2337/dc19-s012.
Centers for Medicare & Medicaid Services. Patient Driven Payment Model; Fact Sheet: NTA Comorbidity Score. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.
Dada, J. (2016, June). Dynamics of Diabetes: Diabetes Management in LTC Patients. Today’s Dietitian, 18(6), 12. Retrieved 2020, from https://www.todaysdietitian.com/newarchives/0616p12.shtml.
Munshi, M. N., Florez, H., Huang, E. S., Kalyani, R. R., Mupanomunda, M., Pandya, N., . . . Haas, L. B. (2016). Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, 39(2), 308-318. doi:10.2337/dc15-2512
Windhorst, A. (2019). Diabetes Control and Nutrition Therapy. https://www.nutritioncaresystems.com/diabetes-control-and-nutritional-therapy