Hosts Marie Brown, MD and Dr. Jill Jin, MD, discuss an efficient team-based approach to managing prediabetes and diabetes, pinpointing opportunities to improve the health of patients while saving care team time.
- Explore the Team-Based Care of Type 2 Diabetes and Prediabetes.
- Explore the Getting Rid of Stupid Stuff toolkit.
- Register for the Team-Based Approach to Treating Prediabetes webinar.
- Register for the AMA Prediabetes Quality Measures webinar.
This podcast episode is supported by Cooperative Agreement number OT18 1802: Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
- Marie Brown, MD; director of practice redesign, American Medical Association
- Jill Jin, MD, MPH; senior physician advisor, American Medical Association
Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Jin: Hello everyone. This is Dr. Jill Jin, senior physician advisor with AMA Steps Forward®. Today on the podcast, we are going to discuss how to apply our time-saving advanced team-based care strategies, which we have talked about many times before on this podcast, specifically to the prevention and management of prediabetes and type two diabetes.
We just published a new AMA STEPS Forward® toolkit on this topic, and I am joined today by Dr. Marie Brown, an internist and the director of practice redesign at the AMA, who was an author on this toolkit. Thanks for joining us, Dr Brown.
Dr. Brown: Glad to be here.
Dr. Jin: OK. So before we delve into team-based management of diabetes and prediabetes, can you tell us why this toolkit was important for you to write? What is the magnitude of this problem and why is it important to address it?
Dr. Brown: Well, diabetes and prediabetes is a huge burden in the American population; 96 million adults have prediabetes. That’s more than one in three adults, and sadly, 80% of people with prediabetes are unaware of it. Now in addition, we know that 37 million people have diabetes and that’s one in every 10 people, and one in five don’t even know that they have diabetes.
The problem is enormous and we have a responsibility to make sure that our patients that we encounter before they develop diabetes become aware of it. Because as you and I know as treating internists, it’s much easier to help a patient recognize the problem before they have gained more weight and can get control of it so that they prevent diabetes with the complications that are so horrific, especially if left untreated.
Dr. Jin: Yes, absolutely. For anyone who needs a refresher, what is the definition of prediabetes versus diabetes?
Dr. Brown: So diabetes generally now is diagnosed with a hemoglobin A1C equal to or over 6.5. Prediabetes is defined as 5.7 to 6.4, and that’s a continuum. It can also be diagnosed with a fasting plasma glucose or two-hour postprandial. If a blood test is done for some other reason, a random glucose of equal to or over 200 is consistent with a diagnosis of diabetes.
So after you see that, an elevated sugar or glucose, you’d want to do an A1C, and remember that the hemoglobin A1C is accurate in most people, but in people who have a changed, a shortened red blood cell survival rate for chronic blood loss or hemolysis and/or people who have a hemoglobin apathy, you cannot rely on the hemoglobin A1C.
Dr. Jin: That’s a good point, that’s a good reminder. So let’s shift to discussing team-based care. So team-based care is a cornerstone for the prevention and management of any chronic disease, including prediabetes and diabetes.
Can you speak more on that in terms of why is team-based care so important in the management of chronic disease and how does it help clinical teams address all the challenges that they face?
Dr. Brown: Well, I think your question is spot on. It’s chronic disease, and so many of our patients have multiple comorbidities. They have multiple chronic diseases. Very few of my patients, and I’m sure it’s your experience as well, have just prediabetes or only diabetes. They usually have hypertension, perhaps they’re suffering from depression.
With excess weight comes arthritic complaints, chronic pain, and it can also result in deconditioning and a very sedentary lifestyle, which continues this cycle of inactivity, weight gain, depression and the addition, then, of comorbidities related often to the initial weight gain.
Dr. Jin: So you need the teams working together to address all of this at the same visit and really coordinate the care.
Dr. Brown: Yes. So a typical patient in my practice was middle-aged with obesity, but they also had six, seven or eight other problems on their problem list and their medication may be as long as 10 or 12 drugs, so it’s a very complicated history and visit because you’re not dealing with one problem.
For the primary care doctor, the internist, the family practitioner, the nurse practitioner, the PA, is addressing five or six or seven very serious issues. Diabetes or prediabetes may be just one, and that’s very challenging, if not impossible, to do alone in a 20-minute visit.
Dr. Jin: Or 15 minutes. So the lack of time, that’s one of the big issues, one of the big challenges.
Dr. Brown: Yes. So the number of problems, the expectations of the patient, the regulations, the pressure to stay on time, to increase volume of patients and, most importantly, the amount of time that is required to be on the keyboard, looking at the computer doing documentation, coding, ordering, is almost impossible then to give the patient your undivided attention.
And that’s what our patients want, to build trust, to have their questions answered, and that relationship is very important. The number one strategy is really to remove obstacles that interfere with patient care.
Dr. Jin: And we talked before about this whole concept of the production line versus solution shop. So as physicians, our job is to be the solution shop, not the production line. A lot of the "production line" work that is very necessary in the management of diabetes and prediabetes can be taken on by the rest of the clinical team.
So maybe let’s go through a patient visit perhaps and provide some examples of what sorts of things can be done by the team, what sorts of routine tasks can be offloaded and addressed by the clinical team in this team-based care workflow.
So the first step, if I’m a patient coming in to see you for a checkup or for an annual visit, who should we be screening and what sort of workflow should be in place to accomplish that?
Dr. Brown: Well, the U.S. Preventive Services Task Force recommends screening for prediabetes and type 2 diabetes in all adults aged 35 to 70 who are overweight or obese. So that in my practice was almost every patient.
In addition, if you look at the standards of care and diabetes, which comes out every January—it’s open access from the American Diabetes Association—their criteria for screening for diabetes or prediabetes, and this is in asymptomatic adults, would include all first-degree relatives with diabetes, high-risk race or ethnicity, African-American, Latino, Native American, Asian-American and Pacific Islander. Anybody with a history of cardiovascular disease, anybody with hypertension or a low HDL, individuals with polycystic ovary syndrome. And really, the most important one that I found was anybody who is physically inactive. So again, that included almost all of my patients.
So anybody who also was diagnosed with gestational diabetes should have testing every three years because that’s a very high risk, and that’s before age 35. And anybody with HIV as well.
An advanced practice provider, nurse practitioner, PA, DO, MD, should be working on solutions and this production type of work, making sure that health maintenance for cancer screening or standing orders that follow U.S. Preventive Services Task Force guidelines, or generally agreed-upon guidelines for a myriad of diseases, should be offloaded and put into the hands and the responsibility of the broader team.
Dr. Jin: Essentially it’s pre-visit planning, right? So let’s say I am found to have prediabetes on a screening A1C that was part of the standing orders that was placed for routine labs, and at the next visit, that’s a diagnosis on my chart as prediabetes.
So then the team would do pre-visit planning and, seeing that diagnosis, they could use another separate standing order set or some other type of workflow that’s in place to place some of these orders for the additional testing and referrals that would be appropriate. So what are some of those examples of the pre-visit planning orders that can be entered?
Dr. Brown: Absolutely. Pre-visit planning is going to save two to three hours a day. I know it did when I implemented it in my practice. So by following agreed-upon standing orders, which is not easy to do. First you have to agree on the standing orders, and we provide some examples in the STEPS Forward® toolkit that this podcast is linked to, so all of that is offloaded.
Through the patient portal, your MA can send out information about what is prediabetes because we want to say that we were lucky that we caught it soon and we can avoid it progressing to diabetes. So the patient education is well-written. The CDC has some wonderful tools, which we’ve listed on the podcast description as well, so that the patient comes in for the visit with the physician, for the first discussion about prediabetes, informed, empowered, and the team has ready the next step.
I’ve heard people say, “Well, my doctor said I had a touch of diabetes five years ago.” Well, that was an opportunity five years ago for that doctor to do what we hope the standing orders and the team approach will accomplish.
We want that person to be activated and provide them a referral immediately to the diabetes prevention program. This is well-funded around the country. We have a link to find your nearest [program] to you. Sometimes they’re associated with the YMCA. They are extremely effective in helping your patient understand what prediabetes is and implement changes, understand the diet, understand the importance of activity so they don’t progress to diabetes.
And that should all be routine, offloaded and automatic so that the physician can answer the questions and explain what the next steps are. We want the patient to have all their answers at that moment and time with a diabetes educator, which takes time. It takes a lot of time, and it can’t be done in that 15-minute, 20-minute visit that sometimes is allotted.
Dr. Jin: Yes, it is so important to underscore how it does require oftentimes multiple visits to explain what prediabetes is and what are the treatment or management principles behind it. And oftentimes if physicians don’t have time to do that weekly, that’s what the Diabetes Prevention Program provides, is that recurrent touch points where they can help take over some of that. It’s a curriculum essentially where they meet weekly and provide some guidance.
Dr. Brown: What’s happening in many offices now, because our patients’ needs are not met, they might call five or six or seven times to have a question answered or to follow up on a test, or the team may receive a test result that should have been present when we were with the patient at the moment. It’s 10 seconds here, it’s 30 seconds there, but it all adds up for the team.
If we do this in an organized fashion and avoid this fragmentation of care, the patient’s needs are served and the team gets back another hour or two each day. We have time then, with those hours saved, to dig a little deeper into the solution aspect for which we’re trained.
It is not easy to identify medication non-adherence. When we ask or the team asks, “Are you taking your medicine?” we really don’t let them say no, because what was the response if we say, “What do you mean you’re not taking your medicine?” So building that trust, we really all have to be so efficient with our time so that we can give the best quality care possible for our patients.
Dr. Jin: Wonderful, well said. So you’ve just described all the reasons why team-based care is so essential in the management of prediabetes and diabetes, but for practices who aren’t using this model or who are just so busy and drowning already as it is, how do you find the time to implement this change, to implement these new standing order protocols or workflows?
How do you convince the team that this is a worthwhile investment? Where do you find the time? What’s a good starting point?
Dr. Brown: Well, that’s a great question. We have resources including a De-Implementation Checklist, things that the organization and your practice can stop doing now, simple things that take up the team’s time, such as things in the inbox, FYI, that really don’t need to be looked at in an inbox, that again takes time away from caring for the patient that you’re with at the moment.
Many organizations have over-interpreted the rules set out by regulatory bodies. We have a toolkit called Getting Rid of Stupid Stuff that are coming via the patient portal or into the inbox, identifying significant opportunities to save an hour or two by simply removing unnecessary messages so that we free up the team’s time so they can think about a team-based approach to managing our patients with chronic diseases, including prediabetes and diabetes.
So I encourage the listeners to look at the De-Implementation Checklist, to look at the toolkit called Getting Rid of Stupid Stuff, so that you can find the time to meet with your team and to get everybody on board.
Dr. Jin: Yeah, that’s such a good reminder that we have to take away before we can add. Before we implement anything new, we have to take something away, off the plates of the care team.
And then one more small point I would add is that you don’t have to start with everything. You start with something small. You don’t feel like you have to implement this entirety of what we just discussed for team-based care at one time, for everybody.
Start with just the A1C or start with just the DPP referral as a standing order. Once the team starts to realize the efficiency gains and the time saved, then I think everyone will become a lot more motivated and morale will increase, and naturally the movement will grow.
Dr. Brown: Exactly. I think that’s a very, very important point and really cannot be stressed enough. And your example, a standing order for every patient with prediabetes to be automatically referred to a DPP program, and for every patient with diabetes to see the diabetes self-management education educator.
Medicare pays for a significant number of hours the first year that a patient is diagnosed with diabetes. Medicare also pays for two hours every year thereafter. So once I discovered that, all my patients with diabetes were expected and they loved it, they had an opportunity to have a one-on-one conversation with a diabetes educator, and it helped answer their questions, it helped them with their diet, and all of that was offloaded so that when I saw them in my office, we weren’t having to talk about diet and exercise. That was already done and done better by a dietician, and we could talk more about the solution issues, their medication adherence, what else is going on with their numerous other comorbidities.
Dr. Jin: Precisely. Thank you so much, Dr. Brown, for joining us today, for sharing this wonderful toolkit that you authored, and for giving us a refresher on the importance of team-based care, getting rid of waste, and practice efficiency.
Dr. Brown: Thanks, Jill. It was great talking with you.
Speaker: This podcast episode is supported by cooperative agreement number OT181802, Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention, or the Department of Health and Human Services.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.