Background: In the US, a small number of patients with complex medical and psychosocial needs disproportionately consume healthcare resources. At our institution, the HOME Program provides dedicated Individualized Care Plans (ICPs) and care coordination for patients with a range of chronic illness. Among such illnesses, Type 1 Diabetes Mellitus accounts for a large portion of recurrent hospitalizations at our institution and nationally. While ICPs have been shown to reduce utilization, less attention has been given to quality metrics such as adverse events.
Purpose: Through implementation of ICPs and multidisciplinary care coordination, the HOME program aims to not only reduce hospitalizations, but decrease severity of illness and rates of adverse events, for our cohort of patients with Type 1 DM. In doing so, we focus efforts to reduce incidence of hypoglycemia, hyperglycemia, DKA and need for ICU admission.
Description: Six patients with Type 1 DM were identified for enrollment, all with greater than four hospitalizations in the preceding 12-months. ICPs were created through chart review, collaboration with endocrinologists, and patient interviews. ICPs contain detailed past medical history, common presentations with suggested management, and discharge planning. All plans contain protocols for managing hyperglycemia and DKA by recommending appropriate order-sets. A fulltime nurse coordinator follows patients longitudinally and collaborates with two dedicated hospitalists, to provide guidance for primary medicine teams. Patients were enrolled between January 21st and December 1st, 2019. Outcomes were collected 24 months prior to enrollment, until November 2021. Mean outcomes for the cohort showed decreased utilization: ED visits decreased from 0.43 to 0.24 per month, hospitalizations decreased from 1.05 to 0.75 per month, and ICU utilization decreased from 15.9 to 7.6% of total admissions. Mean outcomes for our cohort showed a general decrease in adverse events per admission: Severe hypoglycemic events (BG < 54 mg/dL) decreased from 3.3 to 1.5%; while mild hypoglycemic events (BG< 70 mg/dL) increased slightly from 7.3 to 8.3%; DKA events decreased from 29.8 to 20.5%; and hyperglycemic events were unchanged at 78.8%. The mean percentage of endocrinology consultation increased markedly from 4.0 to 64.4% of total admissions.
Conclusions: Our outcomes are consistent with prior findings of decreased utilization with institution of ICPs. More notably, after enrollment our patients experienced on average fewer adverse events. Reasons for decreased severe hypoglycemic events, DKA events and ICU admission, may be from guided reductions in insulin during high risk states, such as PO intolerance, as well as increased endocrinology consultation and use of DKA order sets. Furthermore, additional care coordination and endocrinology input may mitigate severity of illness for subsequent admissions, by optimizing outpatient insulin regimens and compliance. It must be acknowledged that improvements may reflect natural illness course with usual care, rather than direct influence of our program. However, with improvement across multiple metrics, our complex care program shows potential to not only decrease the ‘quantity’ of care but improve the quality of care for our patients. We await opportunity to expand this model to other high-needs cohorts and invite others participating in complex care to target quality metrics, in addition to rates of utilization.