This document summarizes a presentation on enhancing care for nursing home residents with diabetes. Over the past 10 years, Dr. Tan worked with the Salvation Army Peacehaven Nursing Home to improve diabetes care. They developed protocols, training, and resources to transition from nurse-led care to protocol-guided management. As a result, residents experienced reduced hospital transfers, fewer severe hyperglycemic or hypoglycemic events, and care that meets international standards for older adults with diabetes in long-term facilities. The collaboration helped over 100 residents through monthly specialist visits and ongoing staff education.

1. Tele-Continuing Nurse Education
conducted by GeriCare@North
Topic: Enhancing Care of Residents with Diabetes
Date: 14 Aug 2017
Speaker: Dr. Tan Hwee Huan

2. Administrative
• Send your nursing home attendance and any feedback to:
– ktph.gericare@alexandrahealth.com.sg
– Attendance with SNB No. Within 1 week
• Next Tele-CNE Presentation will be on:
– Topic: Management of Residents with Pressure Ulcer
– 11 Sep 2017 at 2.30-3.30pm
– Presenter will be Dr. Vidhya Dharshini Pillay (KTPH)

3. Enhancing Care of Residents with Diabetes
The Salvation Army Peacehaven Nursing Home

4. 10 years @ PH: Year 2008 – 2017
This effort started when the Executive Director of PH, Mdm Low Mui
Lang recognised the need to improve the care of residents with diabetes
& asked if I could join their panel of specialists.
PH then was already engaging specialists (namely Geri-psychiatrist &
Geriatrician) to help manage their residents in the home so as to reduce
the need for them to be brought to the hospitals for follow-up.

5. Population of Residents with Diabetes
0%
10%
20%
30%
40%
50%
60%
70%
Diet Oral Injection Oral/Injection
%
104 residents with diabetes
Residents with Diabetes: Treatment Types
Diet
Oral
Injection
Oral/Injection
2017

6. In the
beginning …
Similar to other specialists – list
of residents for review
highlighted by nurses – varying
numbers for review each visit.

7. Over the years …..
Changes made through team effort

8. Protocol development: 2010 to 2012

9. Problem with Persistently high BG
1.Osmotic diuresis → loss of fluid from polyuria; elder – no
sense of thirst; does not compensate (no polydipsia) →
dehydration → renal failure/hypotension/cardiac
event/death
2.Depressed immune response → increase risk of infection →
sepsis
3.Diabetic emergency – Diabetic ketoacidosis (DKA) or
Hyperosmolar Hyperglycemia Non Ketotic Coma (HHNK)
• Unacceptable FBG: >10.0mmol/L

10. Severe Hyperglycemia – New & Old Residents
Reasons:
1. Transition stress
2. Change in diet
3. Change in medication
4. On going infection
5. Use of steroids

11. Hypoglycemia-associated Autonomic Failure
(HAAF)

12. Visibility
Protocols displayed on
cabinet doors in nursing
room/treatment rooms

13. Development of Blood Glucose Charts

14. Medicines & accessories

15. Moving from dependence
on nurses’ clinical decision-
making to protocol-aided
decision making

16. Progression of training
efforts
• Orientation program conducted by
Doctor; subsequently done by
Diabetes Resource Nurse
• Training sessions for senior nurses
by Doctor
• Participation in KTPH Diabetes
Symposium

17. Benefits of Enhanced Diabetes Care
• Medicines reviewed & adjusted according to needs in Home settings
• Change in lifestyle, esp diet leading to less need for chronic medicines.
• Transition periods may be stressful and adjustments to medicines required.
• Change in glycemic levels due to use of oral steroids, sickday management
and change of feeding method (oral to NGT or vice versa).
• Reduced need for transfers to hospital for review.
• Reduced admissions for severe hypoglycaemia and hyperglycemia
from earlier detection and management.
• Overall, safer care & cost effectiveness achieved.

18. What is the current standards of care
for Older People with diabetes?
How are we compared to
international standards

19. PH: Goals of Diabetes Care for Older People
2010 2013
ADA 2010

20. International Standards of Diabetes
Care for the Older Person

21. Diabetes Care 2016;39:308–318

22. Diabetes Care 2016;39:308–318
5.6 – 11.1

24. 3.9
13.9 – 16.7
Diabetes Care 2016;39:308–318

25. https://www.diabetes.org.uk/Professionals/Position-statements-
reports/Diagnosis-ongoing-management-monitoring/Diabetes-care-for-
older-people-resident-in-care-homes/

26. What’s required
• Diabetologist
• Once a month 3 hour session
• Ad hoc phone consultation
• Conduct CNE for staff 6 – 12m
• Number of residents
benefitting
• Monthly review: 20 – 30
• Overall: 100
Conclusion
Efforts to improve diabetes care
for residents in Salvation Army
Peacehaven Nursing Home
Nursing over these past 10
years have brought diabetes
care for residents up to
international standards of care
for older adults with diabetes
living in long term facility.

27. I’ll like to thank & acknowledge the
Staff of The Salvation Army
Peacehaven Nursing Home,
especially Mdm Low Mui Lang,
Mdm Hong Ho Ying & Mr Thant
Naing Win,
for making this presentation
possible & helping with the slides.