In North Carolina, the numbers are clear: Each year more than 50,000 adults are diagnosed with type 2 diabetes. Another 2.8 million adults in the state have prediabetes—that’s 36.4% of the state’s adult population—which puts them at risk for developing type 2 diabetes if no intervention occurs. But how can physicians and care teams reach those patients, especially in this current climate?

A path to lasting lifestyle change

Give your patients the advice they need to set and achieve sustainable health goals. Explore AMA's resources to help patients create healthy habits.

A new statewide initiative, DiabetesFreeNC aims to put an end to type 2 diabetes in North Carolina, and many of its in-person programs have pivoted to using a distance learning platform to reach patients during the COVID-19 pandemic. As part of the initiative, the AMA, North Carolina Medical Society (NCMS) and other organizations across the state are asking physicians, care teams and health care organizations to lead the way by identifying patients with prediabetes and referring them to an evidence-based National Diabetes Prevention Program (National DPP) lifestyle change program.

To help, Blue Cross Blue Shield of North Carolina has stepped up to prioritize diabetes prevention across the state by providing funding. With an investment of $5 million in a three-year initiative, the costs of enrollment and participation in a National DPP lifestyle change program will be covered, regardless of the patient’s insurance provider.

It’s important now to “make sure that we're keeping people safe and healthy, and that includes preventing and managing chronic disease,” said Neha Sachdev, MD, a family physician and director of health systems relationships at the AMA. “Many National DPP lifestyle change programs have successfully transitioned to and started cohorts by using technology that allows participants to meet virtually. ”

“The current COVID-19 pandemic has changed many people’s daily routines,” said Dr. Sachdev. “Having virtual options for participation allows programs to continue connecting with participants about healthy lifestyles and it may allow some people who previously had difficulty attending in-person programs to participate.”

Many referral options are available

Our Community Health Initiative (OCHI) is a platform that enables physicians to refer patients to a National DPP lifestyle change program through direct messaging in the EHR.

This platform allows the physician or a member of the care team to “push a button that basically sends the patient’s information out of the EHR to the OCHI platform, which grabs it and places them into a National DPP lifestyle change program,” said Franklin Walker, vice president of Rural Health Systems Innovation at the North Carolina Medical Society. “The good thing is after you're running a patient through the program, you can return information to the doctor the same way it came. It’s a seamless interaction.”

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The DPP Navigator is also available to help physicians and other health professionals refer patients to programs. Trained DPP Navigators answer patients’ questions about the National DPP lifestyle change program and coordinate enrollment

Additionally, the NCCARE360 platform allows health professionals to connect patients with social services, including National DPP lifestyle change programs, in their community. A referring physician or a care team member logs into the NCCARE360 platform to create the referral.

Physician champions help spread the word

While the different platforms offer multiple options for patient referrals to a National DPP lifestyle change program, physician champions help spread the word about DiabetesFreeNC.

“We selected three physician champions from North Carolina who are all practicing physicians and they all have patients who are DPP eligible,” said Walker. “Each champion has the ear of the physician community.”

As a physician champion, Brian Klausner, MD, medical director for WakeMed’s Community Population Health program in Raleigh, educates physicians and other health professionals about the National DPP lifestyle change program.

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“We need to empower patients and if we can get patients to eat right and exercise, think about the impact it would have,” said Dr. Klausner who is also chief medical officer of WakeMed Key Community Care. “As physicians, we’re supposed to help our patients avoid bad outcomes and maximize their health. The diabetes prevention program has been proven to do that.”

Learn more about strengthening long-distance care for chronic disease patients.

Patients can be empowered

“With the diabetes prevention program, you do kill two birds with one stone in terms of—yes, it is awesome for prediabetes, but it’s awesome for a whole slew of other things,” said Dr. Klausner. It’s also about “empowering patients to learn about how you live a healthy lifestyle, how you exercise and eat right and improve your health through those lifestyle modifications.”

“There is no better time than right now for patients to get healthy. If we’re going to be battling [COVID-19] for a year or more, now is the time to lose weight, start exercising, eat right and avoid smoking,” he said. “We need to improve upon patient empowerment and specifically bring that more into the environments of the patients and into the home, which this can do.”

The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage the risk of developing type 2 diabetes, including referring patients to a National DPP lifestyle change program based on their individual needs.

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