Diabetes Nurse Case Manager Department of Nursing, Bhumibol Adulyadej Hospital, Royal Thai Air Force

Abstract

Background : Diabetes is common chronic disease that requires a person with diabetes to make a multitude of daily self-management decisions and perform complex care activities. Data of Out Patient Department of  Medicine (OPD-Med), Bhumibol  Adulyadej Hospital were shown approximately 3,000 diabetes patients  were followed up and 15.15 % of  them  had  HbA1C > 9 %.

Material and methods : Diabetes Nurse Case Manager has been working in collaboration with other healthcare professionals to care for three groups of uncontrolled diabetes patient. There  were as follows

1) Diabetic clinic  2) OPD-Medicine, selected diabetes patients who had HbA1C > 10 % for over 1 year and did not follow up with endocrinologist, excluded end stage renal disease and acute Infection disease  and 3) admission at inpatient wards. The methods for outpatient groups were diabetes self-management with home blood glucose monitoring promotion, oral antidiabetic drugs (OAD) and Insulin taking revision and nutrition promotion with focus on some patients who had low body mass index and low income. The methods for inpatient group were nutrition promotion with focus on some patients who had hypoglycemia risk and prevention of revisit with severe hypoglycemia within 28 days post discharge, included end of life care.

Results : The result of each group were as follows 1) The percentage of patients in diabetic clinic service  who reduced HbA1C > 0.2 % during January 2560 to June 2562 every 3-6 months were 80.7 %, 84.1 %,

80.0 %,  85.8 % and 76.6 % in order.  2) There had 70 diabetes patients who were selected in OPD-Medicine during May to August 2560. Starting mean HbA1C was 11.31 % (S.D.1.08), mean of first visit (2-3 months later) HbA1C was 10.13 % (S.D.1.80) with statistically significant lower than starting, at the 0.5 level. Mean of second visit (4-6 months later) HbA1C was 9.65 % (S.D.1.82) with statistically significant lower than starting, at the 0.5 level. There had 60, 100 and 102 patients for other groups later. 3) Inpatient, during January 2560 to June 2562 every 3 months, diabetes patient who had severe hypoglycemia (Point-of-care glucose testing < 50mg %), their average event were 2.3, 2.4, 4.2, 4.3, 2.9, 2.4, 2.1, 2.4, 1.8 and 1.7 time/patient. The percentage of severe hypoglycemia revisiting within 28 days post discharge were 12.5 %, 23.5 %, 3.1 %, 13.7 %, 3.3 %, 9.5 %, 8.0 %, 12.5 %, 10.8 % and 6.6 %, Both of them  were in trends of  reducing.

Conclusions : Performance of Diabetes Nurse Case Manager was presented that many cases of uncontrolled diabetes patient had reduced HbA1C level. The working plan is continuously follow up of these patients and  register patients who are in the first 5 years of diabetes with developing diabetes self-management  education program, improving medication adherence in order to prevent diabetic complication in the future.