August 31, 2012

Diabetes Self-management Education – Part 2

In part 1 of this blog, I discussed much of the importance of diabetes self-management education (DSME) and mentioned diabetes self-management training (DSMT) in mainly the context of use by certified diabetes educators. The article from this link provides much information. There are a few more points to be discussed and emphasized before I discuss more about peer mentors and peer-to-peer workers using this (DSME) to supplement self-monitoring of blood glucose (SMBG).

The topics of depression, physical disability, personal preferences, and quality of life were mentioned and need more emphasis. It is also important to consider hypoglycemia, life expectancy, and the incorporation of other professionals in the care of the elderly. These topics are important for professionals and need to be learned by peer mentors and peer-to-peer workers.

Mild depression for people with type 2 diabetes is about two-thirds of them and less than one-fifth may have severe depression. The article states that the rate of depression in patients is at least two times higher than the general population. It then continues to say the risk of an older person with diabetes experiencing a major depressive episode is 1.6 times higher. I think they mean the general population, but this is not said. The key of why this is important is this statement “Functional disability (difficulties performing activities of daily living and social activities) is significantly increased in the presence of both diabetes and depression, and it negatively affects self-care.” Therefore, screening for depression in the elder population is necessary. If depression if suspected, the depression needs to be resolved before any changes are made to the diabetes self-management plan.

In the previous blog, recent illness or an operation were mentioned, but physical disabilities also needs to be evaluated. The people over the age of 60 may have other physical limitations in performing the activities of daily living (eating, dressing, and toileting). They may also have problems in other areas of daily living such as using the telephone, preparing meals, traveling, and managing finances. Additionally, older adults are at higher risk of hearing loss, vision problems, decreased mobility, falls, fear of falls, and chronic pain.

Patients who are experiencing difficulties with daily tasks will need mandatory individual rather than group DSME. Treatment regimens will need to be relatively simple rather than normal or complex regimens. Learning new skills will take longer and may require referral to a visiting nurse to make sure the task is fully integrated into the patient's self-care regimen. A check back program to evaluate the learning progress may be necessary as well. A physical therapy or local elder services referral may be needed to assess the home environment and prevent potential injury from falls or accidents.

In elderly patients with type 2 diabetes, it is very important to find out what the personal preferences are with respect to care. It is well known that when patients' preferences can be incorporated into care plans, adherence increases, patient satisfaction increases, and the likelihood of improved patient outcomes goes up. Some patients will not need adjustments to their treatment plan, but others with physical or cognitive challenges, may need many adaptive changes.

For the elder type 2 diabetes patients, concern for hypoglycemia is a must if they are on insulin or a combination of oral medications and sulfonylurea is among the combinations. The elderly are more likely to be vulnerable with hypoglycemia occurring at lower blood glucose levels, be harder to recognize, and have poorer outcomes. In the elderly, hypoglycemia may show up in terms of neuroglycopenic symptoms like dizziness, weakness, confusion, and even delirium. This is unlike the symptoms of the younger generations called adrenergic such as tachycardia, palpitation, and sweating. In the elderly, hypoglycemia may aggravate common diseases such as coronary artery disease and cerebrovascular disease. The frail elderly may have outcomes such as injurious falls, even with mild hypoglycemia.

Taking the two diseases mentioned in the last paragraph and adding the two other pathological conditions of hypertension and dyslipidemia to the list and these often dominate the overall health of older patients. Functional status of older people with type 2 diabetes and cognitive decline changes the focus of care treatments from optimizing goals for diabetes to optimizing function and quality of life. The best treatment goals then become achieving the best possible glycemic management allowable, while maintaining independence and optimizing quality of life.

Factoring in that for some elderly with type 2 diabetes, life expectancy may be shorter than the time needed to obtain benefits from an intervention. Before recommending or implementing complicated, costly, or uncomfortable treatment regimens that may result in harmful side effects, it is necessary to realize that there will be reduced adherence to recommended therapies, and reduced general well-being. In other words, the time frame needed to realize benefits should be carefully considered relative to life expectancy.

Two other areas for discussion must include the use of multiple disciplines and care partners in the treatment of the elderly diabetes population. Because older patients with diabetes are clinically and functionally even more diverse than their younger counterparts, therefore they have even greater need for the services of specialists, including nurses, dietitians, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals.

In chronic diseases such as diabetes, day-to-day care responsibilities fall mostly on patients. However, when patients are unable to assume full responsibility for their self-care, family members, friends, or other care partners may need to be involved. In older adults in particular, care partners can play a critical role in managing chronic illness, tipping the balance toward effective rather than failed self-care. If needed, family members or other caregivers should be included in DSME.

Because of the shortage of certified diabetes educators and even the absence of in many rural areas, this is an opportunity for peer mentors, and peer-to-peer workers to fill a need. For the ages about 60, the educators seem to vacate their responsibility and this creates a vacuum that needs filling. This is a reason to become educated in this area and work with the professionals that do care about the health status of the elderly. They, in my limited experience, are willing to share knowledge and give some training.

It is necessary for us to learn what we are able from these caring professional and undertake with their guidance the task of using DSME to assist the elderly diabetes patients. Communication is a must especially back to the doctor by the peer mentor and peer-to-peer worker. Because of HIPAA rules, unless a patient specifically asks the doctor to alert us of his/her medical health conditions, our participation will be severely limited.

Limitations aside, there are some elderly patients being served by peer mentors and peer-to-peer workers and the patients are sometimes filling in the information needed.  Never let the lack of information completely stop you as a peer mentor or peer-to-peer worker as the need for us is there and by learning about DSME and SMBG and other care areas, we will be useful.

Build a network of specialists, including nurses, dietitians or nutritionists, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals, so that if the patient you are working with is in need of their services, you are able to recommend to the doctor, people that are available in that community. The doctor is the only one able to make the determination call and make the referral after evaluating your report and talking to the patient or their caregiver.

Always make a report to the doctor each time you visit a patient you are assigned and make the report as detailed as possible. What you leave out, may make a difference, so include any item even if you prioritize the list. This blog and the previous blog lists many of the areas of concern; however, it is not all-inclusive.

August 30, 2012

Diabetes Self-management Education – Part 1

Diabetes self-management education (DSME) can easily be used in place of self-monitoring of blood glucose (SMBG) to confuse the unknowing public. They both involve education of the patient in management of blood glucose; however, DSME is then taken a few steps further to expand the issue. Both are equally valuable and can be used together. Many of us stop when talking about SMBG at the end of managing blood glucose.

This is where we make the mistake and do not carry the topic as far as DSME does. DSME continues on to include the whole process of diabetes management and takes into consideration the entire patient. For that reason, there has been some separation legitimately in the titles. Sometimes certain groups use the term DSMT (diabetes self-management training). It is a shame that the group that developed this only uses it in writing and self-promotion. This group seldom uses DSME or DSMT in actual practice.

This article is about older adults, but should apply across all ages with modifications. Older patients (age 60 and older) with diabetes do account for more than one-fifth of all patients with diabetes. One statement made in the study that I may repeat is this, and I quote, “Medical care in the absence of adequate self-care is rarely effective for chronic illnesses.” This is an important point and worth emphasizing repeatedly.

DSME is the supposed goal of certified diabetes educators. If they would follow and use it, we could all benefit. Instead, they muddy it up with mantras and do not educate many type 2 diabetes patients. This is their weakness and the importance of DSME should not be diminished. DSME was originally designed for all types of diabetes – again the one-size-fits-all; however, I will be talking about type 2 diabetes for the older generation in this blog and maybe for the younger generations in a future blog.

DSME for those age 60 and older requires, and I mean requires that it be on an individual basis. There is no place for a one-size-fits-all application for the elderly. Where possible it should involve care partners when patients are not able to assume full responsibility for their own self-care. DSME should also consider the potential effects of diabetes treatments on quality of life, but at the same time, encourage all individuals who want to achieve successful health-related care.

Studies of self-management interventions clearly indicate that health behaviors, health status, and health care utilization improve with patient education in diabetes daily care. If only Medicare would stop taking away testing supplies, it might improve even more. One study compared patients that had received some diabetes self-management education with patients not receiving any DSME. Those not receiving any DSME had a fourfold increased risk for major diabetes complications. This alone points out the importance of diabetes education, and the more education the better. This also explains the importance of follow up reinforcement of what they have learned, and asking how they are doing with what they have learned. Be specific and do not accept brush-offs of the questions.

Now the one fault of DSME for the over 60 age group is they are very under-represented in DSME research studies. Therefore, what we have is a set of expert consensus formulated guidelines developed by the American Association of Diabetes Educators (AADE) and the American Geriatric Society. This also highlights the need for other groups that can step forward and fill the need for those with type 2 diabetes. Since the AADE is obviously ignoring the needs of the elderly, this opens opportunities for peer mentors, and peer-to-peer people. With the increasing number of people with type 2 diabetes, and the lack of growth in the AADE, these people will assume roles that are even more important in the near future.

First, we have discussed making sure that the diabetes self-management education is created for the individual and not a one-size-fits-all situation. This should consider how long the individual has had type 2 diabetes. Next, a determination needs to be made of existence of any complications, other medical conditions, and life expectancy. Lastly, is the individual limited in English proficiency, frail, or cognitively impaired as these must be part of the education process and made part of the care partner concerns.

Older adults should be carefully evaluated do determine their knowledge of diabetes and their ability to learn and apply new self-care skills. Social support, transportation availability, financial problems, and functional status must be assessed. Treatment goals and management skills may need to be evaluated frequently to keep pace with changes in functional and cognitive abilities, which can occur relatively quickly.

For the elder generations, nutrition is important. Be sure that the proper nutrition authority is in attendance as problems with the Academy of Nutrition and Dietetics in some states is now the only people that can give nutrition advice unless you are certified by them. Nutrition education is important and older adults must be evaluated to determine if there needs to be changes and to what degree these changes will be followed.

When assessing elder patients' understanding of diabetes and nutrition, a thorough assessment must include individual food preferences, meal preparation capabilities, and potential misunderstandings of adequate nutrition. This should include, but not be limited to dental health, swallowing difficulties, gastrointestinal complaints, decreased appetite, decreased thirst, taste-altering medications, limited finances, and social isolation. Because the diabetes patients are elderly, pushing a fixed number of carbohydrates must be forbidden. Registered dietitians that will not work to the needs and nutrition of elderly patients should not be allowed on a team.

The above is an area of importance for those doing DSME and sometimes they forget about unintentional weight loss as this increases mortality in elderly patients with diabetes. The problem of destructive metabolism is sometimes ignored for these people because acute illness or recent hospitalization is overlooked. Diet moderation, and if medically able, increased physical activity should be considered instead of severe caloric restriction, and should be encouraged in older adults who sincerely wish to lose weight. The goal for individualized planning needs to minimize problems in nutrition management and facilitate changes in eating behaviors. This should be part of the goal to improve clinical outcomes, improved function, and enhance quality of life.

In the elderly, physical activity assessment can be very difficult and should be done in coordination with their doctor. The elderly can often be at increased risk for sedentary lifestyle. This may be caused by recent acute illnesses, coexisting medical conditions such as chronic pain, no safe environment for physical activity, history of falls, and fear of falling. There are many benefits if the elderly diabetes patients are able to exercise, but they should never be forced to exercise. Limited activity exercises need to be investigated when needed and done with their doctor's knowledge.

Other chronic diseases and the number of medications the diabetes patient is taking are important in evaluating potential limitations for the patient. Polypharmacy is the use of several or many medications at the same time. Polypharmacy is always difficult to assess in older patients as many will not tell you what supplements they are taking because they think natural cannot be dangerous. With the conflicts between prescription medications and some supplements, it is important to draw this information out and get them to talk about them. If nothing more, list the supplements that can conflict with the medications you learn they are using.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

An additional assessment needs to be done to evaluate patients and their cognitive abilities to understand when medications need to be taken. Look for signs of depression and physical disabilities that may interfere with medication adherence. This can be very important for the elderly with diabetes and using insulin. Pens may become more important than syringes in many cases and in some instances, it may be necessary to suggest or recommend full care facilities.

Based on the discussion above, consider the following practical pointers for DSME in older adults found to have functional limitations:
1. Choose equipment that is easy to hold and easy to use.

2. When possible, simplify the self-care regimen.

3. Conduct education sessions at a slow pace, with instruction occurring in steps. Use educational material that is easy to follow and excludes extraneous information. Schedule multiple sessions, if necessary, to prevent information overload.

4. Provide individual rather than group education.

5. Recommend further evaluation and treatment of depression and cognitive dysfunction before making any diabetes treatment regimen changes.

6. Use memory aids (e.g., personalized handouts) to reinforce points made during face-to-face sessions.

7. Make sure patients understand how to identify hypoglycemia and when to call the provider.

8. Make every effort to minimize the complexity of meal planning and to engage the patient's spouse or others living with the patient in creating a home environment that supports positive dietary change.

9. Prescribe weight loss diets with great caution.

To be continued in part 2.

August 28, 2012

The Trip to Obtaining Your Medical Records

Now that you are ready to obtain copies of your medical records, make a list of each doctor, period that you were a patient of this doctor, and whether the doctor is still alive or still in practice. Then make a list of medical labs you have used or that your doctors has used, whether they are still in business or not, and locate their address. The purpose is if your doctor is deceased, you may need to contact the labs for test results. Not the best solution, but this may be all that is available to you.

To obtain copies of medical records, you have to be the patient, or the parent of a minor child or the legal guardian of the patient for whom you seek medical records. If you are a caregiver, you may be able to obtain medical records if the patient has provided a legal medical power of attorney to the provider. Verbal authorization generally is not sufficient, but may work for some providers for a limited time. Forget about inquiring or obtaining medical records for your spouse, children of legal age, or parents without legal authorization.

The US Department of Health and Human Services provides background information to help you understand who may, or may not, be able to access your medical records. Providers are required to follow the state rules in which the records are kept. Generally, this means for an adult medical records are kept six or more years. Most children's records are kept three to 10 years beyond the age of 18 or 21. It is always wise to contact the provider to see if the records are still available.

Your doctor or provider is required to share any notes or records they have created or any test results which they have copies. Any information provided to them by another doctor is accessible if that information was used for the diagnosis or treatment being discussed with you. Diagnostic lab tests are a little more complicated, as blood tests, CT scan, x-rays, mammograms, or other tests should be requested from the doctor who ordered them, or from your primary care physician. In most states, the lab will refuse to provide them directly to you. For other records such as hospital records, clinics, or any other medical facility, be sure to request the copies directly from them.

When it involves mental health and related records, this is an area where many doctors will refuse you access. If they do, they must make the reason for denial clear in writing.

Many patients unfortunately believe they or their legal representatives are the only ones that can get copies of their medical records. This is false; there are people that can legally gain access to your medical records without your permission.

When you request copies, most practices, offices, or hospitals will have a form to complete to receive a copies of the requested medical records. They normally will send it to you by fax, email, postal mail, or you may pick it up from the doctor's office. If the facility does not have a specific form, you may write a letter, but be sure to include the following information:
  • your name, including your maiden name (if applicable)
  • make sure that you date the letter for the date of delivery if possible
  • your social security number
  • your full date of birth
  • your complete address
  • your phone number or cell phone number
  • the list of record(s) being requested
  • the date(s) of service when you were under this doctor's care
  • delivery method preferred – pick-up, fax, email, or other method
  • your signature
Deliver the letter or mail the letter to the doctor's office. If you deliver, record in your own records the date the date of delivery and it might be beneficial to have a second copy that the person receiving the letter can sign, date, and show their title.

Now we come to the problem of gettingrecords from a doctor that has sold out, merged into another practice, or had simply left the practice (whether died, quit, retired, or another reason).

If your doctor has left the practice or sold the practice or it was combined with another practice, then the new practice should still have your records. If this is the case, follow the same procedure above as if the doctor was still working in that practice.

If your doctor is no longer in practice, or for some reason you cannot locate the doctor or office where you think your records should be, there are some steps you can take to locate your medical records. These steps include:

1. Contact your local medical society. You may be able to look up the phone number online or in the phone book, or you may find the contact information you need through this list of medical societies in each state. You will need to drill down by state to your local society.
Someone at the medical society should be able to let you know what became of your doctor's practice, and will possibly know where the doctor's records are being housed. They may also be able to tell you how to get copies if the procedure will vary from the basic procedure described here.
2. If your local medical society does not have the information you need, then contact your state medical society association, as per the list linked in #1 above.
3. Finally, if the medical societies cannot help you, then begin contacting other practices of the same specialty in your area. Some doctors will ask other practices of the same specialty to house their records when they close their practices. The idea is, that if your doctor is not in business any longer, then the other specialist might want to pick you up as a patient.
Simply call the office of each of the other same-specialty doctors and tell them, "I was a patient of Dr. ____'s. I am hoping to find my medical records. Can you tell me if Dr. _____ gave them to your practice?" If they say yes, then ask their protocol for getting your copies. If they say no, then ask if they know where those records are being kept. If they do not know, then call the next same-specialty practice and ask them the same question.
4. Finally, if none of these possibilities work out, contact the hospitals in your area. Unless you can determine a better department, then try Human Resources. They may know where your records are being kept.

Keep in mind that when your records have been housed elsewhere, they will be difficult to retrieve unless they are among the minority of records that have already been transferred to an electronic health record. For that reason, you will very likely be charged for the copies you want.  Learn more about how much you may have to pay for copies of your medical records.

August 27, 2012

Your Rights to Obtain Medical Records

This is a topic I started in November2010, and you may review it here. Georgetown University maintains a list of states and the rights for patients in each state that may be in addition to your rights under HIPAA. Please take the time to review the rules for your state, as these are important and can sometimes answer many questions. There is a lot of information available on obtaining your own medical records or those of your minor child. In some states, once the minor attains the age of sixteen, parents may have limited rights.

HIPAA (Health Insurance Portability and Accountability Act) of 1996 created a lot of privacy, but also mandated that covered entities must provide you with copies of most of your medical records. Of course, they may charge you a reasonable fee for them. Some doctors, hospitals, and insurance companies do their best to wear you out as a way of discouraging you and prevent themselves from providing the records.

If you are denied access to your medical records, then you must take steps to obtain them. I will provide the steps necessary, as I understand them. You need to check them and follow them carefully and then if you are denied, you need to file a complaint.

The steps you need to follow are not that difficult, but for many, it can be a nightmare if you meet with rebuffs at every step.

1 - First, make sure you have a right to the records. This is not always as easy as this sounds. Even your own records may become unavailable to you and beyond your legal reach.
2 - Second, be sure that you follow the right steps and procedures for obtaining your medical records. You will need to sign in person the request and follow directions. So make sure you listen to what you are told as this can take several days or even a week or more depending on where the records are kept and personnel available. Most entities will not accept a phone call, and will ignore these requests.
3 - Third, be sure you have made the request from the correct facility. Do not go to the clinic for hospital records. For outpatient records, you may have to ask the doctor who keeps them.
4 - And fourth, have you waited long enough? This is where the state you live in can determine the length. Federal law mandates the longest wait they can delay giving you your records at 60 days.

Many walk-in clinics and places that do not file for insurance reimbursements are not considers covered entities under HIPAA and as such not required to give copies of medical records. Be sure to ask even then as a few will as a courtesy. Be prepared to pay a reasonable fee.

Once you are sure you have met all requirements and are still being denied access to your medical records, you will have 180 days to file a complaint once you are denied. This complaint must be filed with the US Department of Health and Human Services. This information will be in another blog later.

For more explanation, you may want to read this reference.