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 –

• The key is ensuring the right intervention with the right practitioner at the right time.
• The ratios will vary based on your population and acuity levels.
  • Panels tend to be larger with commercial patients rather than with Medicare and/or Medicaid patients.
  • A common ratio seen in complex care programs is one CM per 200 commercial patients or one CM per 50-60 highest acuity patients.

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.

Diabetes Care Transitions in the Hospital: Preventing Readmissions Q&A
with Jane Jeffrie Seley DNP, MSN, MPH, RN, GNP, BC-ADM, CDE, CDTC, FAAD

1. What do you see as a role for the nursing assistant if any?

Nursing assistants can be trained to be partners in care, making sure that patients don’t start eating their meal prior to blood glucose (BG) check and insulin if needed, be alert to signs and symptoms of hypoglycemia, and alert RN to check patient as needed. Nursing assistants can also observe how much of the meal the patient consumes, to alert the RN if the patient ate poorly but received a full mealtime dose of insulin. Although some hospitals allow nursing assistants to check BG, I am not a fan of this practice. As an RN who will be utilizing the BG to dose insulin, I personally prefer that I perform the BG check myself.

2. Does your inpatient meal plan provide carbohydrate content?

Our menu for the controlled carbohydrate meal plan shows the number of grams of carbohydrate for each carbohydrate containing menu item. This serves as a teaching tool for the nurses to use with the patient, and helps guide any substitutions the patient might make from the tray with outside food.

3. How do you teach elderly patients who get confused about the air shot when using an insulin pen?

I provide written instructions and underline the core steps.

• Put needle on pen
• 2 unit “air shot,”
• Dial dose, inject and count to 10
• Remove needle from pen
• Store pen at room temperature with cover on.

Patients with low vision may not “see” air shot so they may have to squirt insulin onto hand to feel it. Important to discuss the importance of this step to make sure needle is placed on pen correctly and to get rid of air bubbles.

4. What strategies do you use to manage patients on short term steroid therapy that is tapered at discharge?

Important for patient to monitor BG at home during steroid taper and to work with their health care provider to make timely insulin adjustments as requirements change.

5. As a nurse practitioner, could you have written the orders for the A1c in the study you referenced?

I could have written the order for the A1c, but the aim of the study was to test the feasibility of offering a program of interventions to high risk people with diabetes with A1c > 9%. It was important that I did not interfere. When I learned that it was taking days to get A1c’s ordered if at all, we modified the inclusion criteria to be A1c >9% OR BGs >180 mg/dL x 2.

6. Do you use U500 insulin in your hospital?

We require an endocrine consult to evaluate whether the patient requires U500 or might be able to be managed on U100. If we decide to keep the patient on U500, pharmacy must draw up dose for safety.

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

¹https://www.acponline.org/practice-resources/business/payment/models/pcm...

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.

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.

Reference to be noted:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf

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.

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!

Questions & Answers

1. These scales are fantastic! Where can we obtain copies to use with patients?

The Diabetes Distress Scale (both the DDS2 and DDS17) is in the following paper:

Fisher, L., Glasgow, R. E., Mullan, J. T., Skaff, M. M., & Polonsky, W. H. (2008). Development of a brief diabetes distress screening instrument. The Annals of Family Medicine, 6(3), 246-252.

Full text of this paper can be found at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2384991/

The Problem Areas in Diabetes scale (PAID) is in following paper:

Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, Schwartz CE (1995)

A copy of the PAID can be found on the following website: http://www.dawnstudy.com/content/dam/Dawnstudy/AFFILIATE/www-dawnstudy-c...

2. When setting behavior goals, I steer the patient to focus on behavior that they can change (like testing blood glucose, making half their plate vegetables, walking for 10 minutes) instead of the outcome of weight loss or glucose control.

• This is a great technique. Helping patients set small, measurable goals can be helpful for several reasons. First, they are able to know objectively whether or not they met their goal (e.g., they either walked for 10 minutes or they did not). Second, achieving small, manageable goals give patients gain a sense of self-efficacy, which can give them confidence that they can take on bigger goals.

3. Why is it that MD's that treat diabetes never ask patients about depression?

• I think there are several reasons why HCPs sometimes do not ask their patients about psychological concerns, including depression. First, many HCPs do not have time to do anything other than address the patient’s primary reason for their visit. Second, many HCPs are hesitant to assess for psychological concerns because they do not have the knowledge or resources to address these issues with their patients, so they avoid asking about them.

4. Do you feel that all people with diabetes should be under the care of an endocrinologist rather than a PCP especially if Hg A1c > 8% for prolonged period?

• In general, yes. However, the type of healthcare provider that a particular person with diabetes sees for his/her diabetes care should be a collaborative decision between that person and his/her healthcare team. If a person with diabetes does not feel they are getting appropriate care from their PCP, or if the PCP determines that the patient would be better served by seeing an endocrinologist, then a specialty referral should be made.

5. How do you manage motivating change and educating patient in regard to knowing what their numbers should be? Do you think education is important?

• I think that providing people with disease and treatment education is a critical part of the diabetes treatment process. It is important to deliver this education in a way that the patient can understand.

That being said, education and motivation are different issues, and education does not always lead to motivation. There are many people with diabetes who know what their numbers should be, yet are still not motivated to change their behavior to manage their condition. We cannot force someone to be motivated. What we can do is to help them see that their behavior affects their glycemic control and support them in discovering that they have the ability to make small changes that will make an impact on their health.

6. I missed your answer to the last polling question (i.e. In a survey of people with type 2 diabetes, over 75% of respondents reported that they)

• In a survey of people with type 2 diabetes, over 75% of respondents reported that they are not sticking closely enough to their meal plan, not sticking to a good exercise plan and are not motivated to keep up with their diabetes self-management. These responses show how important it is to help patients set reasonable goals and expectations for themselves. Diet and exercise are important for diabetes management, but it is not possible for anyone to be perfect all the time. When someone thinks that they have to be perfect and then find that perfection is not realistic, it can really hurt their confidence and motivation to work hard in the future. Instead, it is important to normalize for patients that making these changes is difficult and they may not always be able to do it perfectly. Helping patients understand that they can be successful in their diabetes management, even if they are not perfect, can be very powerful.

Questions and Answers

Are there more materials like your metformin slide that help present information more clearly and in a positive manner? 

That is work that my team is doing, and that approach has been used in a number of risk communication projects. Our idea was to customize the message based on real data that you may have available to you if you work in a large system that can produce that type of data.

What advice do you have for ground level physicians while managing people with diabetes on a daily basis?

Patients need patience. All of the communication skills that I outlined require just as much practice and attention as any other medical skills, but may actually have a bigger impact. The ‘teachback method’ seems to be the most useful to clinicians, but it will take time and energy. Maybe you can engage others to help or link to resources in the community that have something to offer your patients as well. Keep expectations realistic and congratulate on even small, incremental steps.

People are often overwhelmed when they are first told they have diabetes. They are overwhelmed with the diagnosis and the amount of learning that needs to done. How do we put a positive spin on it?  

First, I think you need to recognize that they will not nearly grasp everything in the first visit. You will need to break the information and the goals down into smaller pieces and provide them with just the material for each visit. Most people I have spoken to have found videos of other patients talking about their own experience to be the most helpful. Many of these videos can be found by searching on YouTube or diabetes education sites. You should view them first to make sure that the information is consistent with the messages that you want to convey.  Your main goal is to turn that surprise/fear into commitment and action.

Can you please include the website you referenced with health literacy and numeracy assessment tools? 

The following white paper from the American Association of Diabetes Educators has links in it:  https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/research/aade_health_literacy_and_numeracy_white_paper_final.pdf?sfvrsn=2