As nursing home operators increasingly seek to offer specialized care programs for particular conditions — and as they prepare for coming Minimum Data Set (MDS) changes — their approach to diabetes could present multiple pathways for improvement.
There are actionable opportunities for operators to improve diabetes care for residents, although organizations may be hesitant to adopt them initially, Dr. Naushira Pandya, Medical Director of the State Veterans Nursing Home in Pembroke Pines, Florida and lead author of a JAMDA study on diabetes management in long-term care, told Skilled Nursing News.
“It’s a huge problem in long-term care,” she said, adding that up to 35% of long-term care patients have diabetes. “It’s a complex disease that is associated with a lot of comorbidities, functional impairments, and psychosocial issues, like depression, dementia, and a large risk of cardiovascular complications.”
The study conducted by Pandya and her team represented the largest-scale study for older adults in long-term care. Over the five-year study period, they examined the medication prescribing patterns among more than 71,000 patients in nursing homes.
“We were looking at what medications they were on, what classes of medications, what percentage of people were on oral medications, what percentage were on injectable medications, and then we broke it down into the types of medications,” she said.
From behavioral health to dialysis to respiratory care and more, skilled nursing operators are increasingly seeking to offer advanced care programs. Such programs can help operators enhance revenues, address rising acuity, and gain more referrals from local health systems — and advanced diabetes care offers another route toward these potential benefits.
At the same time, operators should be aware of the health literacy and social determinant of health facets of diabetes, particularly as these elements relate to MDS changes set to take effect in Oct. 2023, executives with Health Dimensions Group told SNN.
Drawbacks of oral medications
Pandya said the limited progress in prescription patterns despite advancements in diabetes treatment is a cause for concern.
“What we did find, and the fact that I would say my conclusion is the practice patterns have not changed a whole lot despite quite significant advances in diabetes treatment,” she said, noting the prevalent use of oral medications.
Pandya said that oral medications are commonly used in nursing homes, despite several disadvantages that can impact residents’ overall care.
“Between 57% to 62% of patients are on oral medications, and Metformin was the most common at 68% and Sulfonylureas at 30%,” she said.
She noted that their limited efficacy in controlling blood sugar levels may result in suboptimal glycemic control and increased risks of complications. Additionally, oral medications can cause side effects such as gastrointestinal disturbances, weight gain, and hypoglycemia, potentially diminishing residents’ quality of life.
“It’s reacting to the high blood sugars, not preventing high blood sugars,” she said. “Moreover, patients have been put on sliding scale insulin without that background long-acting insulin, which is necessary.”
She also noted that the complex dosing regimens associated with multiple oral medications can be challenging for nursing staff, leading to inconsistencies in administration and potential medication errors.
“Sometimes patients receive very small amounts of insulin, dictated by their blood sugar on a sliding scale when they could probably just be on a long-acting insulin or long-acting insulin plus one of the newer injectable agents, like a A GLP-1 receptor agonist, which can be given weekly,” she said.
Newer injectable agents
A GLP-1 receptor agonist (glucagon-like peptide-1 receptor agonist) is a type of medication used in the treatment of diabetes, specifically type 2 diabetes. GLP-1 receptor agonists work by mimicking the action of the natural hormone GLP-1, which is responsible for regulating blood sugar levels. They are typically administered through injection and are used in conjunction with other diabetes medications.
Pandya noted that newer treatments like GLP-1 receptor agonists were much less frequently used in skilled nursing care, accounting for only 2% of prescriptions. Although they typically run more expensive than oral medications, she said there is still potential for cost savings and improved outcomes for operators.
“The challenge could be that some of the newer agents are more expensive than what we have been used to using,” she said. “I would argue that if you look at [how newer medications] improve cardiovascular and renal outcomes, they could be highly beneficial if you look at savings in terms of blood-glucose checking equipment and nursing time.”
She also emphasized their potential to reduce the incidence of hypoglycemia, which 35% of patients in the study had.
Pandya said the findings from the study present an opportunity for all stakeholders in skilled nursing to examine current diabetes management practices and identify areas for improvement.
“I think that this study presents an opportunity for all the stakeholders, the long-term care practitioners, the nursing leadership, administration, to get a more panoramic view of how we’re treating diabetes and see where opportunities exist to simply simplify treatment and to make treatment less complicated and intensive,” she said.
Diabetes and the MDS
Executives at Health Dimensions Group, a management and consulting organization that serves senior living, post-acute, and long-term care providers, said that health literacy can also impact the effectiveness of diabetes care in skilled nursing settings.
The new sections of the Minimum Data set, particularly sections A, B and D, will address social determinants of health, which can be tied to language issues and access to information.
“It can be health literacy, for individuals who don’t know enough about diabetes to age comfortably, and in a healthy way,” Heather Haberhern, SVP of Quality at HDG, said.
Haberhern said that when you combine social determinant factors, such as language barriers, with the fact that many people have comorbid conditions, such as diabetes and dementia, health literacy becomes a very important area to focus on.
“All of this kind of comes together with the idea that as we choose to age at home more, or within our communities, we’re going to have to adjust course in a whole lot of different ways,” she said. “So beginning to collect that data in a different way is really just part of this.”
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