Increasing inpatient attendance to an outpatient diabetes class

M. Weltmeyer , BS, M. Groen, RD

ARAMARK Distance Learning Dietetic Internship Program, Hammond, IN
Abstract
Diabetes self-management education has the ability to lower healthcare costs, reduce
hospitalizations, and prevent additional nutrition related diseases. This type of outpatient education
can only be effective if patients with diabetes are aware of this valuable resource. Hospitalized
patients with a history of diabetes are typically assessed for compliance to a diet regimen, but
nutrition education in a hospital setting can be compromised by time restraints, illness, and
distractions from the high stress environment. Dietitians have the ability to refer appropriate patients
for further nutrition education in an outpatient setting. This study utilized an evaluative design to
determine whether dietitians were able to increase inpatient attendance to an outpatient diabetes
class by motivating their patients and stressing their attendance through personal referrals. A
screening tool, referral checklist, and follow-up reminders were utilized to ensure likelihood of
attendance. Sixty-eight referrals were given over a three month period and eighteen patients (26%)
attended an outpatient class after receiving a referral from a dietitian as an inpatient. Results showed
that clinical dietitians are capable of motivating their patients to continue their education in an
outpatient setting.

Methodology

Discussion

A three-month long study was conducted to assess the impact dietitians can have on increasing inpatient attendance to an outpatient diabetes class. This study utilized an evaluative
design, in which data collection revealed information from before, during, and after implementation of the research. Five clinical dietitians provided written consent for participation in
the study. Each dietitian was expected to make personal referrals to their patients with diabetes who qualified for outpatient education. They were provided with a screening tool to
determine appropriate candidates for outpatient education. A referral checklist was developed and utilized by the dietitians to ensure patients understood the benefits and insurance
coverage of the program. Follow-up reminders via phone were given to patients who needed extra accountability after they were discharged. Patients who received a referral were
recorded and compared to the list of attendees to the outpatient class. A simple yes or no questionnaire was given to the inpatients who attended the outpatient class to confirm they
were referred by a dietitian and to confirm whether or not they received a follow-up reminder.

This study addressed the emerging trend of moving patient care from an inpatient setting to an
outpatient setting. Specifically, this study utilized the motivational skills of clinical dietitians to
further motivate patients with diabetes to continue their health education in an outpatient class.
The results of this study are consistent with findings suggesting that dietitians are able to
increase inpatient attendance to an outpatient class. Through motivation, stressing the need for
class attendance, and providing a class overview, barriers to outpatient diabetes education were
reduced while patients were in the hospital.

1. Screening Tool

2. Referral Checklist

3. Data Tool

Introduction
On average, clinical dietitians spend 20-30% of their time in direct contact with their patients.
Compared to outpatient dietitians, clinical dietitians spend less time with each patient. The patients
condition, time restraints, and distractions created by the high stress environment can hinder
comprehensive nutrition education. One solution to this problem is continuing nutrition education in
an outpatient setting.
Diabetic compliances are used in a hospital setting to assess a patients adherence to a diet regimen.
A brief diet review is given along with a nutrition handout and contact information. Studies have
shown that very few of those eligible for diabetes education receive formal training, and one study
suggested that a physicians influence could positively or negatively affect a patients decision to
attend diabetes education. A diabetic compliance provides an opportune time for dietitians to refer
appropriate patients to further their education in an outpatient setting.
Diabetes affects 29.1 million people. Treatment has evolved from straightforward diet, exercise, and
medications to individualized meals plans, exercise regimens, and self-monitoring of blood glucose
levels. As treatment advances, so does the need for education. The largest component of total
healthcare costs for diabetes is attributed to inpatient hospital care. Diabetes self-management
education can lower hospitalization, decrease healthcare costs, and improve other nutrition related
diseases only if patients are aware of this valuable resource.
Barriers to outpatient diabetes education include the physicians influence on diabetes education, the
patients refusal to change their diet, lack of knowledge about the program, and little concern about
the management of their disease. Dietitians have the ability to decrease barriers to education by
motivating their patients and stressing their need for attendance.
Increasing attendance to a diabetes education class wont stop the prevalence of the disease, but it
could help to increase efficiency and cost of diabetes education. Research has shown that patients
with diabetes need to be motivated, and dietitians have the capability to do just that.

Research Question / Objective

This study will address the following question, Are clinical dietitians able to increase inpatient
attendance to an outpatient diabetes self-management class by motivating their patients and
stressing their need for attendance by making personal referrals?

Results
68 patients received referrals to the outpatient diabetes class
18 patients attended the outpatient class after receiving a referral from a
registered dietitian as an inpatient
Patients who received follow up reminders were more likely to attend the
outpatient class
Speaking directly with a patient was a better method for follow up compared to
a voicemail message
Two patients were excluded from the study due to their absence from class
after signing up
A 10% increase was seen in class attendance from January to March 2015
compared to the previous year

4. Questionnaire

A screening tool suggested by the Adams et al study determined which patients were
appropriate for education based on mental status, age, willingness to learn, and disease status.
This tool appeared effective for increasing likelihood of attendance.
Studies conducted by Funnell et al and Schafer et al suggested that patients either developed a
positive or negative view towards outpatient diabetes education from their physicians. This study
allowed dietitians to speak positively about the benefits of this program, and it shows that
dietitians no longer need to rely on physicians to refer patients to an outpatient class.
The referral checklist was found to eliminate many barriers to education suggested by the study
conducted by Schafer et al. They found that many patients were unaware of the class benefits,
itinerary, insurance coverage, and that the class even existed at all. A complete referral for this
study addressed each of these issues to ensure the patient was knowledgeable about the
outpatient program.
Follow-up referrals were determined to provide accountability to patients looking for extra
motivation. Out of the eighteen patients who attended the class after being an inpatient, eleven of
those patients had received a follow-up reminder compared to the seven attendees who were
recruited solely as an inpatient and opted out of the follow-up reminder.
Limitations to this study included its three-month time frame. Possible attendees were lost for
this study due to later class dates available. The increase in class attendance compared to the
previous year could be do to reasons other than the referrals such as better weather, different
demographics, and the number of class dates offered.

CONCLUSION
Dietitians can play an important role in moving nutrition care from an inpatient to an outpatient
setting. Outpatient diabetes education can only help lower hospitalizations, decrease healthcare
costs, and prevent other nutrition related diseases if people are aware of this resource available
to them. The results of this study suggest that dietitians are capable of referring their patients
through motivation and stressing their patients attendance to an outpatient diabetes education.
Using tools such as the screening tool, referral checklist, and follow-up reminders are crucial for
making successful referrals and ensuring attendance. Further research should be conducted on a
larger scale over a longer period of time to establish the best methods for referral. After
completion of this study, a large number of people are now aware of the services for diabetes
self-management available to them at St. Margaret Hospital.

CONTACT INFORMATION
For additional information, please contact:
Megan Weltmeyer
Dietetic Intern
ARAMARK Distance Learning Dietetic Internship Program
megan.weltmeyer@gmail.com
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