Multidisciplinary Diabetes Management and Education Strategies in the Inpatient Rehabilitation Setting

Abstract

People with diabetes receiving inpatient rehabilitation have multiple unique care needs. Although the condition, event, or disability resulting in admission to an inpatient rehabilitation facility (IRF) may not have a causal relationship with chronic conditions such as diabetes, the condition precipitating referral to IRF care may increase a person’s risk for worsening cardiometabolic disease. Furthermore, diabetes management in the IRF setting may be complicated by stress hyperglycemia from illness and/or drug-induced hyperglycemia from the use of glucocorticoids or other offending medications. The availability of a multidisciplinary team of clinicians and therapists in the IRF setting holds great opportunity for development of robust diabetes care and education programs to optimize therapy, teach or reinforce diabetes self-management survival skills, and facilitate safe transitions of care to individuals’ next setting of care.

According to the Centers for Medicare & Medicaid Services (CMS), inpatient rehabilitation services are crucial for individuals recovering from a serious surgery, illness, or injury that requires intensive rehabilitation, close clinician oversight, and coordinated care from a multidisciplinary team of clinicians and therapists (1). Table 1 provides a summary of medical conditions meeting CMS criteria for referral and receipt of intensive rehabilitative services (2). In addition to the conditions outlined in Table 1, more recent attention has been paid to the potential role of inpatient rehabilitation for individuals with significant functional impairments after a coronavirus disease 2019 diagnosis (3). Although people can receive rehabilitation services in either a skilled nursing facility or an inpatient rehabilitation facility (IRF), rehabilitation services offered within IRFs are generally more focused on multidisciplinary interventions to maximize independence and implement person-specific strategies to overcome functional limitations. Lengths of stay within IRFs can vary considerably depending on individualized rehabilitation needs and reasons for admission.

Table 1.

Medical Conditions Requiring Intensive Rehabilitative Services per CMS (2)

Stroke Spinal cord injury Congenital deformity Amputation Major multiple trauma Fracture of femur (hip fracture) Brain injury Neurological disorders (including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson’s disease) Burns Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies resulting in significant functional impairment of ambulation and other activities of daily living Systemic vasculitides with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living Severe or advanced osteoarthritis involving two or more major weight-bearing joints with deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, and significant functional impairment of ambulation and other activities of daily living Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay in people who also meet one or more of the following specific criteria: The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the inpatient rehabilitation facility admission. The patient is extremely obese with a BMI ≥50 kg/m2 at the time of admission to the inpatient rehabilitation facility. The patient is ≥85 years of age at the time of admission to the inpatient rehabilitation facility.

A large proportion of people referred to IRFs are older adults, many of whom have diabetes. Diabetes increases the risk for many conditions and events that commonly precede referral to an IRF. For example, inadequate diabetes management can lead to serious cardiovascular (CV), neurological, and/or orthopedic complications that may require inpatient rehabilitation (4). Diabetes is also the leading cause of lower-extremity amputation, which often requires an inpatient rehabilitation stay inclusive of intensive physical and occupational therapy intervention (5). Furthermore, nearly one-third of individuals presenting with stroke have a diagnosis of diabetes, with more later recognized as having undiagnosed type 2 diabetes or prediabetes (6). Although most people are discharged home after hospitalization for acute stroke (7), individuals with significant deficits affecting mobility, balance, cognition, and/or activities of daily living may require structured rehabilitation services (8). Indeed, the American Heart Association (AHA) and the American Stroke Association (ASA) recommend that people receive appropriate post-acute rehabilitative care after a stroke to optimize functional recovery and independence (9,10).

Given the high prevalence of diabetes encountered in the inpatient rehabilitation setting, IRFs represent a care setting in which people with diabetes and important comorbidities are readily available for general diabetes education and optimization of their treatment plan to meet their individualized needs and optimize risk management. The care of older adults with diabetes (particularly those receiving care in specialized settings such as IRFs) is complicated by the vast clinical heterogeneity and variability in levels of social support, living situations, and self-care capabilities encountered in this population (11). This article briefly discusses the unique needs, challenges, considerations, and opportunities for robust multidisciplinary diabetes management in the IRF setting.

Diabetes Management in the Inpatient Rehabilitation Setting: Unique Needs, Challenges, and Considerations

Given the varied population receiving care in the inpatient rehabilitation setting, optimized diabetes management involves careful consideration of the unique needs and challenges each person with diabetes encountered. Care coordination and efficient communication among hospital, IRF, and ambulatory (primary and specialty care) providers is crucial to ensure a cohesive and coordinated long-term management plan and strategy. Because day-to-day diabetes management may be affected by a new or recent diagnosis or disability, individuals and their care partners may need and benefit from specialized training to manage preexisting conditions in light of new or emerging changes in health or function. People with diabetes and their care partners may also require adaptive discharge planning, including reevaluation of treatment goals and strategies, which may depend on their prognosis and/or the setting of discharge (e.g., back to home or to a long-term care facility).

Potential Change in Clinical Needs and Priorities

As noted above, a large fraction of individuals referred to an IRF have a history of diabetes. Although diabetes management may have been a priority before their IRF admission, the stroke, amputation, surgery, or other event preceding their IRF admission elevates the crucial importance of glycemic control with regard to their immediate care needs. Furthermore, care planning to effectively address the treatment of chronic conditions such as diabetes, hypertension, and hyperlipidemia is paramount because any post-event disability may increase a person’s risk for worsening cardiometabolic disease. For example, a pragmatic Danish study of people receiving rehabilitation services after a spinal cord injury found that markers of metabolic health such as BMI worsened after rehabilitation discharge (12). The authors recommended meaningful post-discharge support to encourage individuals to exercise and follow a healthy diet when tackling altered life circumstances. Ultimately, the importance of appropriate diabetes care to help ensure immediate and long-term health must be communicated effectively to people with diabetes in IRFs and their care partners within the context of their recent health and functional changes.

Contextualizing Recent Illness With Current Glycemic Patterns

It is also important to contextualize individuals’ current glycemic patterns and needs with the illness or event that precipitated their referral to an IRF. Factors potentially contributing to acute worsening of glycemia may include stress hyperglycemia associated with recent illness and/or recent or current use of medications associated with hyperglycemia. For post-surgical patients discharged to rehabilitation facilities, it is important to consider that the stress of surgery leads to the release of counterregulatory hormones that may contribute to hyperglycemia as well as risk for infections and other complications (13,14).

With regard to medication-induced hyperglycemia, glucocorticoids are a common offender. An estimated 10–15% of hospitalized patients are managed with glucocorticoid therapy, which can result in hyperglycemia in individuals with or without a baseline diagnosis of diabetes (15,16). Management of glucocorticoid-induced hyperglycemia may require insulin therapy, at least in the short term (17). The American Diabetes Association (ADA) states that, if initiated, insulin should be adjusted daily based on the level of glycemia and anticipated changes in type, dose, and duration of glucocorticoid therapy in the inpatient setting (17). Point-of-care glucose monitoring is additionally recommended to minimize both hypoglycemic and hyperglycemic excursions (17). The anticipated need for continued use of agents contributing to hyperglycemia should be considered when formulating a long-term diabetes management plan.

In addition, treatment can be complicated by the significant changes in diet and activity levels that can occur throughout the inpatient rehabilitation period. Significant adjustment of therapies to maintain glycemic control may be required as people transition from enteral feedings to a general diet, experience a variable appetite, and progress from minimal to increased activity as they recover.

Opportunities to Improve Diabetes Management Through Multidisciplinary Care in the Inpatient Rehabilitation Setting

Although there are many potential complications that may affect diabetes management in the inpatient rehabilitation setting, there also exist unique opportunities to provide high-quality diabetes care and education services. The following sections describe these opportunities to leverage the multidisciplinary rehabilitation care team to optimize diabetes care and education and ensure a successful discharge and transition to the next planned setting of care.

Opportunity for a Robust Multidisciplinary Diabetes Care and Education Process

According to the 2022 National Standards for Diabetes Self-Management Education and Support (DSMES) (18), transitions in life and/or care are considered critical times for the provision of DSMES (Table 2). Notably, those referred to inpatient rehabilitation may also be dealing with a new diabetes diagnosis, may not be meeting individualized glycemic goals because of a recent illness, and are likely to be dealing with complicating factors (i.e., a new disability or functional deficit) that precipitated their referral for inpatient rehabilitation services. Provision of DSMES is known to improve glycemia (A1C), medication-taking behaviors, and other diabetes-related outcomes (18). When appropriate, providing education about the link between diabetes and an individual’s new diagnosis or disability (e.g., stroke, amputation, or infection risk) may help to reinforce the importance of diabetes self-management and active participation in the diabetes care plan.

Table 2.

Four Critical Times for DSMES (18)

The four critical times for the provision of DSMES include: 1. At diagnosis 2. Annually and/or when a person is not meeting treatment targets 3. When complicating factors develop 4. When transitions in life or care occur

Knowledge and competency-based diabetes education programs designed to teach so-called “survival skills” in the inpatient hospital setting have been shown to improve diabetes-related knowledge and medication-taking behaviors (19,20). Team-based diabetes care and education in the hospital also has been associated with reduced rates of hospital readmission and costs and higher rates of post-discharge follow-up (21). Similar benefits have been observed with pharmacist-led inpatient diabetes education programs (22).

There are potential challenges, however, with inpatient diabetes education given the general brevity of hospital stays, learning barriers and limitations during acute illness, and staffing limitations. Because IRF stays are generally longer and focused on rehabilitation and skills training, educational programs in the IRF setting hold promise for initial teaching or reinforcement of diabetes self-management skills. Post-stroke diabetes education in the IRF setting, for example, has been suggested as an approach to improve access to DSMES and optimize diabetes outcomes (23).

Few data from DSMES programs initiated in the IRF setting have been reported in the literature. Findings from a small quality improvement project involving implementation of a multidisciplinary, empowerment-based diabetes self-management training class in the IRF setting reported the program to be practically implemented and easily integrated into the existing IRF workflow (24).

Clearly, the multidisciplinary IRF care team lends itself well to the development of robust, multifaceted diabetes care and education programs (Figure 1). Individuals with diabetes receiving care in an IRF routinely engage with a multidisciplinary team of clinicians and therapists to address their individualized medical and functional rehabilitation needs. Although individualized needs may vary from one person to the next, the overall goal is to optimize the diabetes management strategy and engage the people with diabetes and their care partners in structured education to teach and/or reinforce diabetes self-management skills. As shown in Figure 1, the multidisciplinary IRF team is well suited to address a wide range of care and education needs for people with diabetes, including, but not limited to, providing general DSMES, individualized lifestyle education (e.g., individualized meal planning and the development of person-centered activity and hypoglycemia prevention plans), optimization of the medication regimen with tailored education regarding medication management, training on glucose monitoring, cognitive training, and individualized counseling to promote social adjustment and motivation to engage in the established management plan. The multidisciplinary team can also meaningfully contribute to the development of an individualized discharge plan to promote individuals’ successful transition to their next setting of care.

Figure 1.

Proposed multidisciplinary comprehensive diabetes care and education program in the inpatient rehabilitation setting. CDCES, certified diabetes care and education specialist; DSME, diabetes self-management education; OT, occupational therapist; PT, physical therapist. Image created with BioRender.com.

Opportunity to Initiate and Optimize Organ-Protective Therapies in Appropriate Individuals

Guidelines for the management of type 2 diabetes have evolved dramatically in recent years, informed by the results of landmark CV, kidney, and heart failure (HF) outcome trials (25–27). The ADA recommends that optimization of glucose-lowering therapies in type 2 diabetes address two primary goals: 1) cardiorenal risk reduction in high-risk individuals and 2) achievement and maintenance of glycemic and weight management goals (25).

With regard to cardiorenal risk reduction, the ADA specifically recommends the use of a glucagon-like peptide-1 (GLP-1) receptor agonist and/or a sodium–glucose cotransporter 2 (SGLT2) inhibitor with proven cardiovascular disease (CVD) benefit in individuals with established atherosclerotic cardiovascular disease (ASCVD) and those with indicators of high ASCVD risk. In the case of people with type 2 diabetes and comorbid HF, the ADA recommends the use of an SGLT2 inhibitor with proven HF benefit. In those with type 2 diabetes and chronic kidney disease (CKD), the use of an SGLT2 inhibitor with primary evidence of slowing CKD progression is recommended (25). If standard-of-care SGLT2 inhibitor therapy is insufficient to achieve and maintain individualized glycemic targets in the setting of type 2 diabetes and CKD (or if the person is otherwise unable to take an SGLT2 inhibitor because of intolerance or a contraindication), a GLP-1 receptor agonist with proven CVD benefit is preferentially recommended (25,28).

Recommendations from other guideline-issuing organizations are largely in line with current ADA recommendations for cardiorenal risk reduction. The 2021 AHA/ASA guideline for prevention of stroke recommends that people with type 2 diabetes experiencing an ischemic stroke or transient ischemic attack should be managed with glucose-lowering therapies with proven CVD benefit to reduce the risk of future major adverse cardiovascular events (i.e., stroke, myocardial infarction, and CV-related death) (29). Furthermore, the AHA/ASA guideline recommends multidimensional care and follow-up, including lifestyle counseling, medical nutritional therapy, and DSMES, to achieve individualized glycemic goals and to improve stroke risk factors (29). It has been proposed that initiation of these recommended therapies should be considered in the acute care setting. For example, an expert consensus report published in 2020 by the American College of Cardiology identified hospital discharge after admission for an ASCVD event as an opportunity for initiation of GLP-1 receptor agonist and SGLT2 inhibitor therapies for CV risk reduction, provided close outpatient follow-up is provided (30). Although initiating these guideline-directed medical therapies during a hectic hospital stay may pose logistical challenges, initiating them during an IRF stay may be more feasible and allow for robust training and education on the purpose and appropriate use of organ-protective therapies, supported by the multidisciplinary IRF team.

Opportunity for Robust Transitional Care Handoff to Next Setting of Care

Transitions in care are fraught with potential miscommunications and medication-related errors and thus represent high-risk times for people with diabetes (11). The risk for adverse outcomes during care transitions is particularly high for individuals who are older; have complex comorbidities, limited health literacy, and/or cognitive impairment; and take multiple medications (often defined as five or more prescribed medications) (31,32). People with diabetes receiving inpatient rehabilitation often have one or more of these risk factors.

The ADA’s Standards of Care in Diabetes—2024 (17) states that a structured discharge plan should be tailored to individuals with diabetes upon discharge from the hospital to the ambulatory care setting (17). A structured discharge plan for individuals being discharged from an inpatient rehabilitation setting to their next setting of care is no less important. Table 3 summarizes recommended components that comprise a reasonable framework for the development of person-centered discharge plans for people with diabetes who will be leaving an IRF (17).

Table 3.

Minimum Components of an IRF Discharge Plan

Component	Details
Medication reconciliation	Home and facility medications must be cross-checked to ensure that no chronic medications are stopped and to ensure the safety of new and old prescriptions. Prescriptions for new or changed medications should be filled and reviewed with individuals and their care partners at or before discharge.
Structured discharge communication	Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient health care professionals. Discharge summaries should be transmitted to the primary care clinician as soon as possible after discharge. Scheduling follow-up appointments before discharge, with people with diabetes agreeing to the time and place, will increase the likelihood that they will attend.
Review of and provision of education as needed for key areas of knowledge before discharge	The health care professional who will provide diabetes care after discharge should be identified. Individuals should be assessed for their understanding of their diabetes diagnosis, glucose monitoring routine, and home glucose goals, as well as when to call a health care professional. Initial or refresher education should be provided on the definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia. Individuals should receive information on making healthy food choices at home and a referral to an outpatient registered dietitian nutritionist or diabetes care and education specialist to guide individualization of their meal plan, if needed. People should be advised on when and how to take blood glucose–lowering medications, including administering insulin and noninsulin injectable medications. Pre-discharge education should include sick-day management. Proper use and disposal of diabetes supplies (e.g., insulin pens, pen needles, syringes, and lancets) should be reviewed.

Adapted from ref. 17.

Conclusion

The clinical and educational needs of people with diabetes who are referred to an IRF require careful consideration to optimize care and outcomes. Although people receiving care in an IRF may be focused on the specific condition or disability resulting in their referral for rehabilitation services, the IRF stay provides a unique opportunity to optimize the diabetes care plan to mitigate cardiometabolic risk and provide a robust, multidisciplinary, person-centered diabetes education program. Provision of such services will not only improve the IRF stay, but also empower people with diabetes and their care partners for success as they transition to the next planned setting of care.