Antonio is at high-risk for diabetes. He is 65 years old, Hispanic, smokes, is overweight, does little physical activity, has high blood pressure and a family history of diabetes, all of which are risk factors for developing diabetes. Antonio feels fine so he doesn’t seek care. Antonio doesn’t realize it but he is developing diabetes. Statistics show that there are 7.2 million adults that don’t know they have diabetes.
Antonio starts to notice that his vision is blurry, he is more tired than usual and the sore on his foot is not healing, all signs of diabetes. He decides to see his doctor because he doesn’t want to lose his foot like his father. His doctor sends him for blood work. Antonio’s blood sugar is 350mg/dl and his HgA1is 11%. An HgA1c > 9% is considered poor control and is one of the diabetes quality indicators that is tied to his physician’s reimbursement as it is a marker for potential costly complications.
Antonio is diagnosed with diabetes and given a prescription for a pill to lower his blood sugar. If his physician was following clinical guidelines for type 2 diabetes, Antonio would have been started on insulin as his HgA1c was >10%. It has been reported that only 53% of physicians follow diabetes guidelines routinely. Antonio is instructed to test his blood glucose daily, stop smoking, lose weight, increase his activity level and return to the clinic in three months.
Antonio feels overwhelmed and anxious about all the things he needs to do to manage his diabetes and worries about his future with diabetes. He is experiencing “diabetes distress” which is linked to poor health outcomes. Because he doesn’t want to miss another day of work, Antonio decides to skip his follow-up appointment and stops taking his medication because he feels better. Antonio is part of the 33% of patients that stop taking their medication earlier that instructed.
Six months later, Antonio’s sore on his foot worsens and gets infected. His doctor’s office is closed so he decides to go to the ED where he is admitted for treatment to heal his wound secondary to his hyperglycemia. He is also given insulin to bring down his blood sugar and discharged two days later with instructions to continue taking his insulin and follow up with his primary care physician. The discharge nurse is unaware that Antonio has many barriers that will negatively impact his glucose control as her responsibility is to make sure he understands his discharge instructions. These uncovered barriers include: difficulty paying for his insulin; language barrier; low literacy; and his belief that insulin could cause further health problems.
Antonio returns home, ignores discharge instructions, stops taking his insulin because he believes that’s what caused his father’s amputation. Antonio’s blood glucose levels rise and he returns to the ED for another preventable, costly admission.
In 2016, Pennsylvania adults admitted for diabetes often had multiple hospitalizations. Overall, 5.4% of patients were admitted three or more times for diabetes with medical costs 2.3 times higher than those who do not have diabetes.
I'm sure we all have an “Antonio” story to tell. Where are the care gaps in your facility? What can you do (or have you done) as a CDE to close those gaps? So many opportunities await...………..it's time to showcase our talents and help close those care gaps so patients like Antonio have a happier ending and a better life.
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