Speakers: Dr. Michael Vallis, PhD R Psych and Janice Knapp, BN RN, CDE
"I’m scared and alone": Let’s Reveal solutions to support our patients beyond COVID-19
Speaker: Mary Ann Hodorowicz, RDN, MBA, CDCES, CEC
(May Update) Telehealth DSMT, MNT & Medicare Waivers Per COVID-19 Emergency
Speaker: Mary Ann Hodorowicz, RDN, MBA, CDCES, CEC
(April Update) Telehealth DSMT, MNT & Medicare Waivers Per COVID-19 Emergency
Speaker: Speaker: Jerry Meece, RPh, CDE, FACA, FAADE
The Diabetes Care Team Part 2: The Evolving Role of the Pharmacist
Speaker: Jerry Meece, RPh, CDE, FACA, FAADE
The Diabetes Care Team Part 1: New Concepts and Approaches
Speaker: Teresa Pearson, MSN, CDE, FAADE
Managing Populations, Treating Individuals
Webinar Description: Population health management is designed to improve the health of a defined patient population and relies on the ability to provide individualized support at and between clinic visits. Teresa L Pearson, MS, RN, CDE, FAADE discusses population-level strategies to organize and deliver care to people with diabetes.
Managing Populations, Treating Individuals Q&A
with Teresa Pearson, MSN, CDE, FAADE
Is there a recommended nurse to patient ratio for population health?
This is a very common question. The answer is “it depends.” If you consider that not all people with diabetes (PWD) are at high risk all the time and only about 10-20% will be at high risk at any given time, one care manager can possibly handle well over 1000 or more people. The payer mix also plays a part in the Care Manager (CM) to Patient ratio. For a high-risk population to CM ratio, you might consider something like 200:1 as long as there is access to a team of people who can help with various aspects of the care – but the CM is the person coordinating it all.
Another approach is that the CM is doing EVERYTHING for those high-risk patients. In this model the ratio might be more like 15:1. Your primary determinant of whether you have the right ratio is if you are meeting your goals. If not, you need to look at the process and ratio is part of that.
Part of the role of the CM (many of whom are Registered Nurses (RNs)) is to delegate services based on need. RNs do not need to be on the phone setting up appointments for people to come in for follow-up or for new labs – a Medical Assistant can do that. CMs may be on the phone with some high-risk individuals several times a week, and for those who are well-managed (the majority) they may only be in contact once every three months or if they rise to the high-risk category the CM will need to reach out.
Bottom line –
Speaker: Jane K. Dickinson, RN, PhD, CDE
Language in Diabetes Care and Education
Webinar Description: Representatives from the American Diabetes Association and the American Association of Diabetes Educators released a consensus statement about the use of language in diabetes care and education. The statement provides recommendations for language used by healthcare professionals and others when discussing diabetes through spoken or written words. Jane K. Dickinson, RN, PhD, CDE, reviews the components of the statement and share how healthcare professionals can engage in nonjudgmental language that places the person with diabetes before the disease.
Language for Diabetes Care and Education Q&A
with Jane K. Dickinson, RN, PhD, CDE
1. The star measures interfere with this goal setting ability as the providers are held accountable, not the patient in the payer world
Yes! I agree, and we have a lot of work to do advocating for changing the language of billing, coding, documenting, etc. That is one of the reasons it’s so important to spread this message about the difference language can make.
2. Do you feel that people use broad language because they do not know the terminology to communicate or document useful information?
I believe people use the language they hear and see all around them. As healthcare professionals, we have been hearing the same negative, judgmental words since we were in school (and even before if we were ever patients). I agree that until people hear about the language movement and understand why it matters, they are not likely to change.
3. DAWN Study - do you or the American Association of Diabetes Educators have recommendations for the linguistic validation of questionnaires/scales/instruments when this information is moving from one language to another?
I would recommend contacting the folks directly connected to the DAWN studies. As far as moving from one language to another, if you are referring to more inclusive, respectful and empowering language, that is something I would love for someone to study! I do not believe there are any studies or recommendations for studies at this point. AADE does have two resources available at www.diabeteseducator.org. Click on practice then educator tools, which would help with wording for future research materials.
4. Non-adherence is also a statement of fact.
While “non-adherence” is, indeed, a statement of fact if someone is not doing what the healthcare provider wants, it is the message behind it and the lack of information that is the problem. “Non-adherence” is a judgmental statement, which does not build on people’s strengths or empower them to take care of themselves. In addition, “non-adherence” doesn’t give us any helpful information. Why aren’t they taking medication, or doing whatever it is that we hope they will do? That is what’s important to find out and move forward.
5. As a facilitator of two groups of patients with Type 1 and one group with Type 2, I have surveyed 45 people with diabetes, and 45 out of 45 report not being offended when they are referred to or self-referred to as type 1 or 2 diabetic. I have type 1 and it doesn't bother me either.
Many, if not most people with diabetes refer to themselves as “diabetic.” This is a reflection on what they have heard and been called for their entire diabetes life (so far). People with diabetes are often not aware of the stigma attached to the word “diabetic” or the fact that “diabetic” doesn’t provide helpful information. By using person-first language and referring to “people with diabetes” or “people living with diabetes” or “people who have diabetes” rather than “people who are diabetic” or “diabetics” we are acknowledging that the person is more important than the diagnosis. We are not labeling the person as their disease, and we are focusing on what we have, rather than what we are. This is empowering. It is very important to emphasize that the language movement in no way dictates or even suggests what people with diabetes call themselves. We are simply encouraging healthcare professionals to set a precedent by using strengths-based, person-first language.
Speaker: Juan Pablo Frias, MD
American Diabetes Association Standards of Medical Care in Diabetes 2018: Latest Updates
Webinar Description: The American Diabetes Association’s Standards of Care provide the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2 or gestational diabetes. In this webinar, Juan P. Frías, MD, reviews key revisions in the 2018 standards of care.
Speaker: Mark Heyman, PhD, CDE
Healthcare Provider Burnout: How Do You Cope?
Webinar Description: Healthcare provider burnout is increasing in prevalence and poses a threat to our healthcare system. Burnout was a syndrome identified 30 years ago, and is characterized by depersonalization, emotional exhaustion, and a sense of low personal accomplishment. Characteristics of the healthcare environment coupled with personal factors place healthcare providers at risk for burnout.
Healthcare Provider Burnout Resources
Mark Heyman, PhD, CDE
Patient-Centered Medical Home and Burnout
According to the American College of Physicians, Patient-Centered Medical Home (PCMH) is a care delivery model in which patient treatment is coordinated through their primary care physician to make sure patients get the care they need, when and where they need it, in a manner they can understand.1 The goal of the PCMH is to have one setting that facilitates partnerships between individual patient and their personal physician. There have been several studies that suggests the PCMH model can improve job satisfaction and decrease provider burnout.2,3 However, the consensus is more research needs to be done to fully understand how this model decreases provider burnout. Current hypotheses include staffing levels, an emphasis on participatory decision making, and the proportion of time team members can spend working to the top of their competency level.3
2 Reid, R. J., et al. (2010). The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs, 29(5), 835-843.
3 Helfrich, C. D., et al. (2014). Elements of Team-Based Care in a Patient-Centered Medical Home Are Associated with Lower Burnout Among VA Primary Care Employees. Journal of General Internal Medicine, 29(S2), 659-666.
Measures of Burnout
The Maslach Burnout Inventory1 is the most commonly used instrument to measure burnout, and has been used by researchers to measure burnout in healthcare professionals (HCPs).2 The Maslach Burnout Inventory looks specifically at the three dimensions that have been used to define HCP burnout: emotional exhaustion, depersonalization, and personal accomplishment.2
1 Maslach, C., & Jackson, S. E. (1981). Maslach Burnout Inventory--ES Form. PsycTESTS Dataset.
2 Poghosyan, L., Aiken, L. H., & Sloane, D. M. (2009). Factor structure of the Maslach burnout inventory: An analysis of data from large scale cross-sectional surveys of nurses from eight countries. International Journal of Nursing Studies, 46(7), 894-902.
Speaker: John Sears, PhD, MBA
Value-Based Care in Managing Type 2 Diabetes (T2D): From Healthcare System Dynamics to Quality Measures
Webinar Description: Value-based care has emerged as a solution to address rising health care costs, clinical inefficiencies and duplication of services found within the traditional fee-for-service delivery model. Value-based care is designed to achieve the best outcomes at the lowest cost and is a shift from a supply-driven health care system to a patient-centered system.
Value-Based Care in Managing Type 2 Diabetes Webinar Q&A
John Sears, PhD, MBA
Question: Do you know why STAR's monitors nephropathy by urine testing only even though the person with diabetes may have a nephrologist following his/her kidney care?
Answer: This is an excellent question, which will shed light on to the complexity of measure development and need for clarity to the measure specs to understand their exact implications. The above question is looking to understand the nuances to care coordination for people with diabetes who have kidney disease – how to reconcile where and how nephrology testing is conducted versus what the quality measure counts as meeting the goal.
The diabetic nephropathy measure that CMS adopts for its Medicare Star program is titled, “Medical attention for nephropathy,” and was adopted from the HEDIS measure set. It’s defined as, “A nephropathy screening test or evidence of nephropathy, as documented through administrative data. This includes diabetics who had one of the following during the measurement year:”
- A nephropathy screening test (Nephropathy Screening Tests Value Set)
- Evidence of treatment for nephropathy or ACE/ARB therapy (Nephropathy Treatment Value Set)
- Evidence of stage 4 chronic kidney disease (CKD Stage 4 Value Set)
- Evidence of ESRD (ESRD Value Set)
- Evidence of kidney transplant (Kidney Transplant Value Set)
- A visit with a nephrologist, as identified by the organization’s specialty provider codes (no restriction on the diagnosis or procedure code submitted)
- A positive urine macroalbumin test (Positive Urine Macroalbumin Tests Value Set)
- A urine macroalbumin test (Urine Macroalbumin Tests Value Set) where laboratory data indicates a positive result (“trace” urine macroalbumin test results are not considered numerator compliant)
- At least one ACE inhibitor or ARB dispensing event (Table CDC-L)
Bottom line: There are several assessments that can be conducted in order to test for nephropathy, which includes, but is not limited to, urine testing only.
Thank you again for this very interesting question.
Speaker: Kim L Kelly, PharmD, BCPS, FCCP, CDTC, CPC, CEC
Overview of Landmark Clinical Trials in Diabetes
Webinar Description: Landmark clinical trials are trials that have significantly influenced clinical practice, and there are several clinical trials that are well known for their implications in diabetes prevention and control. Kim Kelly, PharmD, BCPS, FCCP, CDTC, CPC, CEC presents the landmark clinical trials that have most influenced the clinical practice of diabetes.
The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive glucose therapy in patients with newly diagnosed type 2 diabetes was associated with a reduced risk of microvascular complications and a non-significant reduction of 16% in the relative risk of myocardial infarction. Since these patients were newly diagnosed, the study may not have been long enough to see a significant reduction in cardiovascular disease usually associated with atherosclerosis. However, in a subgroup of patients whose body weight was more than 120% of their ideal weight and who primarily received metformin, reductions in the risk of myocardial infarction of 39% and of death from any cause of 36% was observed. Since intensive glucose control with metformin appears to decrease the risk of diabetes-related endpoints in overweight people with diabetes and does a better job in decreasing risk long term than insulin/sulfonylureas, this could be one of the findings that led to its consideration as perhaps the first-line pharmacological therapy of choice in these patients. The initial results of the UKPDS, which were published in 1998, were influential in subsequent diabetes management considerations and the decision was made to continue observing these patients to see how various therapies did over the longer term. In an additional part of the UKPDS related to blood pressure control, the cardiovascular benefits of reaching average targets of 144/82 were dramatic and significantly better than when glucose targets were attained. While initial and follow-up publications of benefit from tight(er) glucose control were significant, we also learned of the legacy effect of early glucose control, the significant role played by metformin in glucose control in obese patients, and the benefits of tight(er) control of blood pressure. This study has contributed greatly to our understanding of good diabetes treatment and its benefits!
In patients with type 1 diabetes, the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/ EDIC) study reported a post-interventional microvascular benefit and the emergence of macrovascular risk reduction from earlier improved glycemic control in follow-up observations now spanning over 30 years! In the DCCT, enhanced risk reductions occurred despite the loss of within-trial differences in glucose levels when patients were followed up in the EDIC continuation, which reinforced the understanding of a legacy effect from tight glucose control.
In a desire to further our understanding of the benefits of glucose and blood pressure control (and to some extent lipid control) several major trials in patients with type 2 diabetes were initiated around the world. ACCORD (primarily US), ADVANCE (primarily outside the US) and VADT (US only) studies looked at the potential for benefits of even tighter glucose control (than achieved in most large trials) in individuals with long standing diabetes with significant risks for or previous events from macrovascular disease. While the studies were relatively short in duration, there seemed to be little benefit and some potential harm in trying to get A1C levels down to ‘normal’ (roughly 6%). A striking finding of all three studies is the suggestion that a beneficial effect of the glycemia-control intervention is more likely in association with shorter diabetes duration. In the published report of the ACCORD study, participants entering with baseline A1C < 8%, rather than having an adverse effect of intensive glycemic treatment on mortality, showed a significant reduction in the primary outcome favoring more intensive glucose control. Similarly, in the ADVANCE trial, the combined micro- and macrovascular primary outcome benefit of the glycemia control intervention was seen in participants without a baseline history of macrovascular disease, with similar findings in the VADT. Likewise, more intensive control of blood pressure did not yield significant benefits suggesting that the levels targeted by current guidelines are appropriate in people with diabetes.
There were two questions at the end of the presentation:
1) Is there any information from SBGM data related to the ACCORD problems?
Interestingly, while subjects in the ACCORD trial received free SMBG products, the data from their meters was only downloaded by a fraction of the trial sites, and I have only seen one presentation where such data was discussed. The presentation was by Dr. Richard Bergenstal of the International Diabetes Center, and was delivered at the Advanced Technologies and Treatments in Diabetes meeting a couple years ago. In that presentation, Dr. Bergenstal showed data suggesting that there was a higher level of glycemic variability in individuals who had died than in patients who did not. It is quite surprising that meters were not downloaded regularly and the data used in an attempt to further understand the outcomes in the ACCORD trial.
2) Would a take-home message be that only the DCCT and EPIC studies demonstrated a significant reduction in cardiovascular events with tight control (the other studies showing no effect of adverse effects)?
Yes and No… The benefits of tight control in a younger population with type 1 diabetes are clearly evident and seem to persist for up to 30 years! However, in older, complicated type 2 patients with long standing diabetes and significant cardiovascular risk, studied in ACCORD, ADVANCE and VADT, the benefits seem to be less pronounced, at least in the short durations of those trials. A meta-analysis of all three studies which pooled their data did show a small but statistically significant improvement in cardiovascular outcomes overall. In further dissecting these outcomes, it appears that people with diabetes of lesser duration, people with lesser cardiovascular risk, those who had better glucose control at baseline, and those whose glucose lowering was more gradual seemed to benefit the most from tighter glucose control. This suggests (as do all the studies) that the earlier you get good glucose control the better the outcomes will be for your patients. ACCORD taught us to be more thoughtful in the targets we choose, and current guidelines echo that lesson.
Speaker: Maggie Powers, PhD, RD, CDE
Diabetes Self-management Education and Support: A Joint Position Statement
Webinar Description: Diabetes self-management education (DSME) is a critically important and fundamental element of care for all people with diabetes and those at risk for developing the disease. DSME is a collaborative process through which people with diabetes gain the knowledge and skills necessary to modify their behavior and successfully self-manage the disease and its related conditions. The purpose of DSME is to support informed decision making, self-care behaviors, problem solving and active collaboration with the health care team in order to improve clinical outcomes and quality of life for people with diabetes. The ultimate goal of DSME is to reduce the burden of diabetes on individuals, families, communities and healthcare systems.
Speaker: Juan Pablo Frias, M.D., FACE
Diabetes Standards and Guidelines: Medications and Monitoring
Speaker: William Polonsky, PhD, CDE
Meaningful Monitoring Revisited
Speaker: Jerry Meece, RPh, FACA, FAADE, CDE
ACEing Adherence in Diabetes Care
Webinar Description: Diabetes is a challenging disease to manage due to the multitude of therapeutic recommendations and the need for lifelong adherence. Reasons for non-adherence are multifactorial, difficult to identify, and common in individuals with diabetes, which makes target glycemic control difficult to attain.
If you were kind enough to sit through my recent webinar on ACEing Adherence in Diabetes Care, you might recall that I made mention of using analogies when working with patients as a way of making a point. Analogies are stories or word pictures that help explain concepts and possibly decrease resistance by providing the patient with familiar situations that they can identify with. One example of an analogy I referred to was, "Not monitoring your blood sugar is like driving down the highway without an oil light, speedometer or gas gauge." Another was, "Your blood glucose measurement by a finger stick is like a Pliaroid snapshot for a moment in time. Your A1C is like a full length movie."
Whether teaching patients or speaking to workshop groups, I love using these forms of story telling as they go a long way toward helping the listener not only understand, but also to remember a point long after our time together is over. Because of the limited time I had during the webinar I could only use quick examples of how I used analogies, so I wanted to give just a few other reasons why I think they are so effective, at least in my style of teaching and speaking.
1) Since the dawn of man we have been used to listening to stories, whether around the campfire or in the company of our parents. For most people, morals and lessons taken from stories are one of the most enjoyable ways to learn.
2) Analogies enhance our comprehension of difficult and hard to grasp subjects. If we can identify our learning with something more familiar to us, we understand and retain that knowledge for a longer period of time.
3) Analogies break up the learning process and help us to pay closer attention to what is being said because the subject is less abstract and more a part of our everyday world. Using analogies in a conversation makes the exchange of information less formal and likely more acceptable.
So as you work to make your classes and interactions with patients more effective, I hope you consider the use of analogies as a way to make a point and enhance learning. Also, if you use an effective analogy or have a key way to make a point, please share it with the rest of us on the Johnson & Johnson Diabetes Institute message board!