Diabetes Management under a Physician Shortage

In the next few years, what are we, as diabetes patients going to be able to do? There is going to be a physician shortage which we have been hearing about from doctors and their professional organizations. Even teaching professors are talking about this and a few patients. How long are we going to be forced to wait between appointments and think about how much time the doctor spends with you now. This can only be worse and your questions may not even be answered.

Ann Bartlett, who writes at Health Central dot com has an excellent blog on July 17 that deserves your attention. She is a type 1 and in this blog writes for all people with diabetes. Because of what she writes about the numbers of practicing endocrinologists, I will disagree with her statement that everyone should see an endocrinologist at least once a year. Some people will do very well in the early stages of diabetes, especially those with type 2 diabetes that do not need to lose weight or that are able to manage their diabetes with nutrition and exercise. Many people do probably need to lose some weight and are capable of doing so.

Where I do agree that people with type 2 needing to see an endocrinologist are those people with complex diabetes and often comorbidities requiring more attention than a primary care physician (PCP) has time to devote to the patient. Many of these patients are in the need of insulin therapy, but the PCP has not kept abreast of the knowledge required and so won't prescribe insulin. Instead, he has stacked one oral medication on top of another and in some unusual cases, the patients are taking up to four different oral medications. Too many and most of the time they still are having trouble maintaining good A1c's.

Ann is right when she says, “Third-party insurance providers, the big bad boy of this debate, are finally hearing the bell toll, and need to start offering fair reimbursement to doctors for services rendered.” Unfortunately, with the Centers for Medicare and Medicaid Services not expanding their payment to PCPs and endocrinologists, the rest of the insurance industry will not step forward and help, as they want to grow their profit margin. So our doctors are continually squeezed in the pocketbooks and wallets.

As a result, I will continue to advocate for state medical boards to loosen their strangle hold on nurse practitioners and physician assistants and allow them to operate with more independence. This blog has a map showing the states that are allowing NPs the freedom to practice medicine without supervision. Only 18 states are presently allowing this. It is a shame that the same information is not available for PAs. My endocrinologist has at least two NPs on his staff and I see one of them. I also see a NP at my Veterans Affairs (VA) appointments and I am very happy with both.

The American Association of Diabetes Educators (AADE) could really help with education, but at present, they are reluctant to do so. I have been on their case for some time now and all it has gotten me is derogatory emails. Even my CDE cousin will not talk to me anymore because she knows I am serious.

The AADE is not adding CDEs at a rate needed to serve patients adequately. Therefore, the AADE should be required to open up a classification or group for peer-to-peer workers and peer mentors, give them some training and classes, and let them move out into the diabetes community and help people with all types of diabetes. Then they should provide continuing education for them. This is supported by several studies where peer-to-peer workers have helped other type 2 patients lower their A1c's. This would work for type 2 helping type 2's and type 1 helping type 1's.

Even the ADA and AADE Task Force that developed the Diabetes Self Management Educations (DSME) and the Diabetes Self Management Support (DSMS) National Standards included lay people and peer workers in the area requiring more research, yet the AADE has chosen to ignore this. Oh, yes, they will take credit for the CDC programs that they participate in for training peer workers, but will they open a designation for them and continue to assist them with more education – no. They can't wait to be separate from them and let them go their way. This is not the correct attitude to my way of thinking, especially with the shortage of certified diabetes educators.

Fortunately, some doctors in rural areas and some not so rural areas are seeing the need for peer-to-peer workers and peer mentors and having them educated. Then they are returning to help their doctor and other doctors in their areas. One doctor that I started to work with in Montana, now has three peer mentors in three chronic diseases doing what needed to be done for education of his patients.

Another area that needs to be opened up is telemedicine where doctors could practice across state borders and others could assist people in doctor sparse regions of the country.

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.