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Introduction

Glycemic goals for long-term care (LTC) residents with type 2 diabetes mellitus (T2DM) should be individualized based on the presence of comorbidities, life expectancy, hypoglycemia risk, and other considerations.¹ Basal insulin with or without rapid-acting mealtime insulin is often an appropriate pharmacologic modality for achieving glycated hemoglobin A_1c (HbA_1c) goals, as it provides the most predictable glycemic control while circumventing the contraindications and potential adverse effects associated with other antidiabetes medications.² Insulin use is on the rise in the LTC setting. In a recent analysis of 11 531 LTC residents with T2DM, overall insulin use increased from 51.7% in 2008 to 68.3% in 2010.³ In particular, the use of rapid-acting insulin markedly increased from 11% in 2008 to 29.4% in 2010.³ These trends may reflect increasing comfort levels around the initiation and intensification of insulin therapy for LTC residents.

When a hospitalization is necessary for an LTC resident with T2DM, the period of transfer to and from the hospital is a vulnerable time. LTC residents who are hospitalized face an increased risk of infections, complications, reduced functioning, and medication errors.⁴ In a study of 110  161 recently hospitalized Medicare home healthcare beneficiaries with T2DM, the 30-day hospital readmission rate was 20%.⁵ The presence of certain comorbidities significantly increased the risk of hospital readmission, including heart failure, chronic obstructive pulmonary disease (COPD), renal failure, and difficulty managing medications.⁵

With improved collaboration among all members of the healthcare team, approximately 1 in 3 hospital readmissions among older patients with T2DM can be prevented.⁵ Consultant pharmacists can take a leadership role in implementing best practices around medication management and other strategies designed to decrease preventable hospitalizations in the LTC setting.

The American Diabetes Association (ADA) defines a successful care transition for LTC residents as a process during which designated healthcare providers validate the necessity of the hospital transfer, clarify discrepancies in the patient's care plan, and address any issues to ensure a safe outcome.¹ Poorly managed care transitions can increase the risk of repeat hospitalizations, which represent a major burden for LTC residents, clinicians, and the healthcare system. Each year, LTC facilities transfer approximately 25% of their Medicare residents to hospitals for inpatient admissions at a cost of $14.3 billion.⁶ Moreover, wide variations in LTC hospital transfers are observed in facilities that are rated 1, 2, or 3 stars by the Centers for Medicare and Medicaid Services (CMS) Five-Star Quality Rating System that had higher hospitalization rates than those rated 4 or 5 starts (26.7% vs 22.8%, respectively).⁶ To address excess LTC resident hospitalizations, CMS recently proposed a new quality measure that will influence Medicare reimbursement rates. Beginning in 2017, all skilled nursing facilities (SNFs) participating in Medicare will be required to publically report their resident hospitalization rates.⁷ By 2018, a national ranking structure for SNF hospitalizations will be in place, and Medicare reimbursement rates for SNFs will be adjusted according to their performance relative to national quality standards. The Medicare reimbursement penalties for SNFs related to high readmission rates are projected to total more than $2 billion over 10 years.⁷