Diabetes, also called diabetes mellitus, is a group of diseases characterized by high blood sugar caused by problems with insulin production or absorption in the body. Chronic high blood sugar can result in long-term damage, dysfunction and even failure of organs like the eyes, kidneys, nerves, heart and blood vessels.
Type 2 diabetes is the most common form of diabetes, accounting for as much as 95 percent of cases in the United States. 1 Effectively managing diabetes can help patients maintain a healthier lifestyle and help prevent more serious conditions like heart failure, high blood pressure, stroke, wounds and kidney disease.
Patients who are eligible for home health benefit from interdisciplinary care at home that offers diabetes education and care tailored to their needs. A home health plan specifically created for patients with diabetes can help empower them to manage and improve their condition and long-term outcomes.
What is a Home Health Care Plan and How Can it Help with Diabetes?
Home health care plans allow nurses, patients and other medical professionals involved in a person’s care to stay on the same page with goals of care and outcomes. While plans will vary among providers and organizations, most include the core components of patient diagnoses, desired outcomes, patient teaching and follow-up assessment to make sure the plan is effective.
In home health care specifically, the agency’s care team and the physician work with patients to create a plan of care that includes and outlines:
- The types of services you need, which may include skilled nursing, physical therapy, occupational therapy, social work, home health aides and more
- How often you need these services
- Any home medical equipment you may need
- Any specific dietary requirements
- Your doctor’s goal for the treatment
- The patient’s goals for treatment
Goals for Diabetes Patients in Home Health Care
While every patient will have a unique treatment plan and goals, these are the most common goals for successful diabetes management:
- Teaching healthy habits to control glucose levels and prevent complications
- Empowering patients to understand and monitor diabetes symptoms
- Managing medications
- Improving functional strength and mobility
- Learning to protect their feet and do daily foot inspections to prevent wounds that can lead to amputations
- Establishing a daily exercise routine to match pace and ability level
- Achieving patient-centered goals and improving quality of life
- Reducing hospitalizations related to diabetes complications
How Does Home Health Nursing Help Patients with Diabetes?
Skilled nursing care is the most common home health service and is one of the most important parts of home health care in helping patients manage diabetes at home.
Home health professionals help educate patients on how they can take control of their own health to manage the disease. This includes following a proper diet, exercising and knowing how to correctly self-monitor for signs of dangerously high or low blood sugar. These clinicians also help patients learn to monitor glucose levels, ensure medication adherence and set up nutrition and activity-level goals while in the home.
What is Included in a Nursing Assessment for Diabetes?
When a home health nurse assesses a patient with diabetes, they look at a holistic picture of how the diagnosis affects the person, and what is needed to help manage diabetes better. The nurse will assess for:
- Low energy, thirst, frequent urination
- Blurry vision
- Numbness or tingling in hands/feet
- Wounds that heal slowly
- Any recent changes in weight
- Usual meals and snacks
- Sugary drinks or alcohol
- Portion sizes
- How consistent meals are
- What diabetes medicines the person uses
- Whether doses are taken on time
- Any side effects
- Whether the person understands why they take each medication
- How often blood sugar is checked
- What the usual numbers look like
- Whether the person knows what to do if numbers are too high or low
- Daily movement
- Exercise routines
- Barriers like pain, fatigue, or lack of time
- Stress
- Burnout from managing diabetes
- Support at home
- What the person knows about their condition
- Whether they understand food labels
- Whether they know how to prevent complications
How Home Health Supports Diabetes Treatment
Home health nurses and therapists work together with the patient and the patient’s care team to plan diabetes treatment that helps improve health and well-being. Specifically, the home health care team focuses on the following:
Assessing Glycemic Control
Glycemic control is the delicate balancing act of keeping blood sugar levels within a normal range and, if successful, can reduce complications like nerve, eye or kidney problems.
Physicians set each person’s glucose goals based on factors like how long they have had diabetes, their age and life expectancy, coexisting health conditions, known complications and more.
Leading organizations like the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE) and the International Diabetes Federation (IDF) each have their own recommendations on goals as measured by A1C (a lab value that shows average blood sugar control over a 3-month period) and pre- and post-meal blood glucose levels.
The home health team and doctor will assess each patient’s medical condition and ability to be an active part of managing their glycemic control.
Glucose Monitoring
Glucose monitoring is an essential skill for managing diabetes and assessing treatment outcomes. Continuous information on blood sugar levels, collected at home, helps the home health team and physician assess patients’ progress and ability to live with this chronic disease.
The frequency of at-home, self-administered glucose testing depends on the treatment plan, plan of care goals, financial limitations and patients’ ability and willingness to test.
Home health professionals will help each patient understand how often they should check their glucose levels, how to get the right equipment, how to perform the tests and act on the results.
Medication Management
Drug therapy is a key component of diabetes management by mimicking the body’s natural process of metabolizing and using glucose. For type 2 diabetes patients, oral medication may be adequate. The home health team will help the patient balance the need for medication with other lifestyle changes like weight loss, diet changes, increased activity and less carb consumption.
For type 1 diabetes patients and some type 2 diabetes patients, injection therapies, including insulin injections, can be used if oral medication is not keeping blood sugar under control or the patient is undergoing surgery, another illness or pregnancy.
Home health nurses will help the patient understand both the type of medication therapy they need and the correct dosage. As part of the first home health visit, clinicians will assess whether they believe the patient or caregiver to be capable of self-administering injections based on cognitive or vision impairments.
Nutrition Therapy
Nutrition therapy can help improve glucose and HgA1C. 2 Dietary interventions have the following goals:
- Promote and support healthful eating patterns with emphasis on a variety of nutrient-dense food in appropriate portion sizes to improve health and attain goals
- Achieve and maintain desired body weight
- Delay or prevent diabetes-related complications
- Address individual nutrition needs based on personal or cultural preferences, health literacy, access to healthy food choices and more
- Provide patients with practical day-to-day meal planning tools
- In the early stages of type 2 diabetes, losing weight is the primary goal. Research shows that losing 5 to 10 percent of body weight can significantly improve glucose control. 3
The home health team will educate the patient on successful, practical weight loss strategies like switching from calorie-heavy drinks to diet sodas or sugar-free drink mixes, changing snacks from packaged products to fruits and vegetables, decreasing portion sizes and eating at home more frequently.
Moderating carbohydrate intake is also critical to nutrition therapy. Successful carb moderation is not eliminating them entirely, but rather consuming the right kinds, like fruits and whole grains, in the appropriate balance with fat and protein.
The “Plate Method” helps patients visualize what an appropriate meal should look like to meet the goals. In this method, half of the plate should be filled with non-starchy vegetables, a quarter with a starch and the final quarter with a protein. Adding a serving of fruit is also recommended.
Increasing Physical Activity
Physical and occupational therapists will instruct the patient on regular exercise that can improve long-term glycemic control and help reduce the need for insulin or other medications.
Exercise can also help reduce stress, help maintain a healthy weight, lower fat levels in the blood, reduce the risk of heart disease and promote overall health. Any exercise regimen should be individualized to the patient and have approval from the physician.
The home health team will often encourage patients to increase their activity levels, starting as little as 10 minutes a day 3 to 5 times a week, increasing gradually to as much as 45 minutes on most days.
A combination of aerobic exercise, like walking, and strength training is recommended for the greatest benefit. Patients are also encouraged to have a caregiver or family member accompany them on walks or other forms of exercise to improve their experience and commitment.
Home health clinicians will also help patients navigate any specific challenges to exercise and remind them to check glucose levels before beginning any activity.
Amedisys' Diabetes Program
Amedisys home health agencies offer an evidence-based diabetes management empowerment program for patients whose primary diagnosis is diabetes. Specifically, the Amedisys program:
- Engages patients in self-care to better manage symptoms at home and identify early signs of complications
- Addresses other illnesses like heart failure and high blood pressure
- Teaches how to monitor blood sugar levels and recognize signs of diabetes-related complications
- Provides home health diabetes teaching on healthy habits including lifestyle changes, wellness, diet, exercise and medication management.
If you believe you, your loved one or your patient might benefit from home health care and the diabetes program, call a location near you to get in touch with a home health specialist.
*Use of this material does not create physician-patient relationship. The information included in this material is not intended to be a substitute for professional medical advice. This material may not include all information available on or related to the subject matter discussed herein. Consult your doctor or other professional healthcare providers with any questions regarding a medical condition or before starting or changing any treatment.
Melanie Morris, MBA, MSN, RN, COS-C is the Assistant Vice President of Care Delivery Management for Amedisys. In her 28 years as a nurse, she has enjoyed caring for many types of patients and is passionate about providing holistic care to patients in their homes, especially those with chronic conditions such as wounds.
references1. https://gis.cdc.gov/grasp/diabetes/diabetesatlas-statsreport.html 2. https://link.springer.com/content/pdf/10.1186/s12986-025-00968-3.pdf |
