Topic: Care Delivery Challenges for Nursing

Topic: Care Delivery Challenges for Nursing

Topic: Care Delivery Challenges for Nursing

Among factors that affect nurses’ role in caring for patients with diabetes are the complexity of the health care system, inadequate measurement of nursing performance, and reimbursement issues. Most diabetes care occurs in outpatient settings. But there are no specific models or frameworks other than case management to guide nurses in supporting diabetes self-management education interventions. Because they’re not well defined and measured, nursing interventions aren’t considered a discrete component of care. Few if any third-party payors recognize nursing services that aren’t bundled with medical management and, therefore, nursing services are not directly reimbursed. Nurses’ work depends on medical management plans, and physicians’ slowness to adopt evidence-based treatments may interfere with nurses’ establishment of successful patient self-management plans.


A review of the literature yielded few studies on outpatient nursing and delivery of diabetes care. Three studies of nurses as diabetes case managers produced excellent short-term outcomes. In all three studies, nurses were assigned to a specific subset of patients and were responsible for assessment. The nurse case manager created a self-management plan and followed up with patients by phone, home visits, and other reminders to come in for lab work and other screenings. These interventions resulted in improvements in glycosylated hemoglobin (HbAIc) and in patient satisfaction. But the studies did not address the questions of whether results could be maintained beyond the short term and whether this level of resources could be sustained. Topic: Care Delivery Challenges for Nursing

A systematic review of nursing interventions for patients with chronic conditions showed that patients benefited by nurse follow-up. This review noted that patients with diabetes showed health benefits and improved psychosocial outcomes when nursing follow-up was part of their care.

In a systematic review of diabetes management in primary care, Renders and colleagues examined 41 studies that targeted changing either system elements (such as a revision of professional roles or changes in medical records) or health professionals’ behavior (often through educational meetings). They found significant improvements in both patient outcomes and processes of care when these interventions included enhanced roles for RNs, such as patient education. However, nurses were just part of the solution; multifaceted professional and organizational interventions leading to regular patient review were the key to improving care.

When van Dam and colleagues reviewed eight randomized, controlled trials examining the effect of patient–provider interaction and provider consulting style on patient self-care and diabetes outcomes, they found that outcomes were better when interventions were patient-centered rather than those that changed provider behavior.

According to a study conducted in Washington state, although about 90% of diabetes management is provided to outpatients in primary care settings, health care systems are designed to meet acute care needs. The Chronic Care Model emphasizes collaborative interaction between well-prepared health care providers and patients to promote improved care delivery and cost-effective, quality care for chronic conditions. (See Figure 1, “The Chronic Care Model,” in “Diabetes Care: The Need for Change,” page 14.) While the Chronic Care Model does help to refocus attention on chronic conditions, it does not address or acknowledge any one discipline’s contribution. But there is a strong nod to supporting best medical practice and use of the best medical evidence.


Many of the major randomized, controlled diabetes trials have nursing-based protocols for patient management and follow-up. Yet these interventions have not been reported as separate, independent variables, and their effects have not been directly measured. This omission underscores the lack of recognition for nursing‘s contribution to outcomes.

Funnell and colleagues surveyed 361 certified diabetes educators, most of whom were RNs practicing in outpatient settings and providing direct clinical care, diabetes education, and outreach. Their programs used empowerment and patient-centered and behavior-change curricula more often than older didactic models. Respondents indicated that while they had control over the content and delivery of their education programs, they had much less control over program budgets. The diabetes educators felt that physicians did not fully understand or value their contribution to patient care.

In an effort to identify the essential interventions of diabetes educators and link them to measurable outcomes, the American Association of Diabetes Educators has developed the National Diabetes Education Outcomes System (NDEOS). The system generates a database that not only serves the individual educator but also contributes to a national database on diabetes education outcomes. The focus is on seven areas of behavioral change: eating, activity level, medication management, monitoring, problem solving, risk reduction, and coping.

As part of the NDEOS, tools have been developed to use with patients and to systematically collect data from which performance reports can be generated. These tools enable measurement of diabetes education processes and outcomes. Nurses who maintain a diabetes treatment practice can receive feedback regarding their own effectiveness while at the national level the aggregated data may offer the power to determine specific effects of diabetes education. The University of Pittsburgh recently reported positive outcomes of using this NDEOS approach within the context of the Chronic Care Model. This may be the first viable model for refocusing and refining the delivery of outpatient diabetes care. (See “A Diabetes Self-Management Education Program” on page 62 for more on how this program has been financially successful.)


In the past 15 years, evidence has mounted showing that good glycemic control can prevent the long-term complications of both type 1 and type 2 diabetes. There is a growing awareness that poor glycemic control and adverse outcomes are not solely a function of the patient’s behavior. For example, a treatment that is not well matched to the patient’s condition and circumstances may not result in the desired outcome. A patient with type 2 diabetes may be prescribed diet and exercise, as well as metformin (Glucophage and others), upon diagnosis. But if the diagnosis occurs late in the disease, insulin production may already be markedly reduced, and additional hypoglycemic agents may be needed. The patient may be fully compliant, but the treatment is not sufficient to achieve glycemic targets. As a result, the patient may become frustrated and indifferent to the need for diligent self-management.

The lag in appropriate medical management, including follow-up and intensification of medical therapy as needed, is called “clinical inertia.” Even in trials in which fewer than 40% of subjects achieved glycemic targets, providers were not inclined to intensify therapy. Berlowitz and colleagues found that clinical inertia in diabetes care can be measured by a predictive modeling approach, using number of patient visits, intensity of treatment, and HbAIc values. The researchers found that application of their model provided a measure of clinical inertia that predictably correlated with poor glycemic control.

Ziemer and colleagues found higher rates of treatment intensification in patients at a diabetes clinic than in those at an internal medicine clinic. Only the diabetes clinic used a team approach that included a strong nursing component. But the authors dismissed this as an explanation for the better outcomes in the diabetes clinic patients because previous research had shown that patient education without pharmacotherapy has only a modest effect. The truth may be that both approaches are necessary to achieve targeted outcomes. Topic: Care Delivery Challenges for Nursing

Clinical inertia may occur because busy practices inadvertently overlook important aspects of care. Griffin and Kinmonth reviewed five trials involving 1,058 people and found that a computerized recall system that prompted general practitioners and patients led to both more organized delivery of care and better patient outcomes. Yet a systematic review of the literature on audit and feedback cautioned that automated cues and prompts resulted in only small to moderate benefits in practice outcomes. The reviewers concluded that cueing and feedback systems, such as reminders for ordering measurement of HbAIc and follow-up visits, are necessary but not sufficiently robust by themselves to produce and sustain improvements in outcomes. Topic: Care Delivery Challenges for Nursing

For nurses engaged in diabetes care, clinical inertia is significant because self-management education and care planning flow from an accurate diagnosis and an appropriate medical treatment plan. “Medical clinical inertia” resulting in inadequate medical treatment plans impedes or unnecessarily delays nurses in establishing effective patient self-management plans. Nurses, too, must keep up with evolving patient care.


The costs associated with diabetes treatment—$92 billion in 2002—have garnered the attention of both private insurance and government payors, which determine who treats and educates patients and what supplies and equipment will be used with their reimbursement policies. Insurers are looking at diabetes management programs that attempt to control costs and improve quality, which could include programs that encourage better self-management and increase patient responsibility for compliance with the care plan. Topic: Care Delivery Challenges for Nursing

Coverage by many third-party payors is based on treatment outcomes, especially those that are easily tracked and have been shown to reduce costs. The evidence is clear that glycemic control for patients with either type 1 or type 2 diabetes can slow or prevent end-organ damage. Specific pharmacologic agents have been shown to be effective in preventing, in particular, eye, kidney, and nerve damage. There is also evidence to support behavioral changes, specifically diet and exercise, as ways to prevent or delay the onset of diabetes. The challenge is to incorporate these changes into clinical practice in an affordable way.

Third-party reimbursement also is predicated on industry standards of quality set by accreditation agencies. The National Committee for Quality Assurance measures the quality of managed care services, using the Health Plan Employer Data and Information Set targets. Diabetes targets include performance of eye and foot examinations and monitoring HbAIc levels. At present, there are no comparable targets for nursing practice, either for patient self-management education or for follow-up. Topic: Care Delivery Challenges for Nursing

Industry standards are also affected by Medicare, which sets the structure for fees, types of services, frequency of contact, and type of provider for patients older than age 65. Nursing is directly influenced by Medicare’s reimbursement process because of its determination of the frequency and number of hours for education, and the amount and conditions of payment. Nurses need to be a valued and distinctly visible part of this payment system. At the present time, nursing practice in support of diabetes self-management is not specifically identified, measured, or tracked in any standardized way.

A concerted effort is needed to better define and increase the visibility of nursing practice in diabetes self-management. Changes must be well grounded in evidence, with better studies of nursing interventions and outcomes and use of evidence to support nursing activities. Nursing practice must be tracked to demonstrate that self-management interventions improve patient outcomes and are cost-effective. Only in this way is reimbursement for nursing services likely to become a reality.

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