Managing Type 2 Diabetes

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This toolkit 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.

How Will This Toolkit Help Me?

Provides an efficient team-based approach to managing prediabetes and diabetes
Pinpoints opportunities to improve the health of patients with prediabetes and diabetes while saving care team time

Introduction

Diabetes is a complex illness requiring a lot of effort for patients and their care teams to manage. Identifying patients with prediabetes and intervening early to prevent progression to diabetes is paramount. The good news is that simple interventions can make a big difference and save time. Successful management can be achieved with multiple small steps.

Q&A

How big of a problem is diabetes in the United States?
Diabetes presents a massive burden for people and health care providers in the United States:
- Approximately 11% of the US population has diabetes, representing 37 million Americans¹
- Diabetes is the seventh leading cause of death in the US¹
- Among adults, type 2 diabetes accounts for over 90% of cases¹
- 121.6 million physician outpatient visits in 2017 were attributed to diabetes²
- 1 in 4 health care dollars is spent on the care of people with diabetes²
What is prediabetes, and how big of a problem is it in the US?
People with prediabetes have blood glucose levels higher than normal but not elevated enough to be considered diabetes.³ Approximately 96 million—or 1 in 3— adults in the US have prediabetes.³
Why screen for prediabetes?
People with prediabetes are at increased risk for developing type 2 diabetes, heart disease, and stroke.¹ Approximately 80% of people with prediabetes are unaware of their status.

Eight STEPS to Efficient Team-Based Diabetes and Prediabetes Screening and Management

Engage Your Team
Evaluate How Patients' Poor Glycemic Control Impacts Your Practice
Choose 1 Aspect of Diabetes Care to Address First
Choose 1 Aspect of Prediabetes Care to Address First
Pilot an Intervention With Your Team
Support Your Patients With Education
Use Shared Decision-Making When Developing Treatment Plans
Screen for Social Determinants of Health and Commit to Advancing Health Equity

STEP 1 Engage Your Team

Early on, engage the entire clinic team, including front desk personnel, medical assistants (MAs), nurses, and other team members, to lead change. A team invested in the process who knows the practice values their input is more willing to help shape the new approach.

Consider having periodic meetings with team members to:

Educate on diabetes, glycemic control, and standard laboratory tests
Emphasize the importance of screening for and managing prediabetes in your patient population, including an overview of the National Diabetes Prevention Program lifestyle change program
Brainstorm, answer questions, and address issues about changes to processes or workflows

Involve the MAs on the care team in diabetes education through a professional development program. This way, the MAs are trained to answer questions about diabetes-related lab tests ordered as part of pre-visit laboratory testing, during the rooming or discharge process, or when a patient receives a visit summary or results through the patient portal. MAs who expand their skills and are engaged in everyday diabetes care are more likely to feel that their work is worthwhile—resulting in greater contributions to team-based approaches to patient care or population health for your practice.⁴

A special guest lecturer, such as a pharmacist, diabetes educator, nutritionist, administrator, or patient, can enhance engagement while contributing to your team's understanding of all aspects of diabetes care and management.

Q&A

Why should we include a patient in our team meetings?
Having a patient attend helps the care team understand the barriers to achieving optimal glycemic control from the patient's perspective. Understanding these barriers is the first step toward addressing them effectively.
Why should we include an administrative leader?
Involving administrative leadership in any improvement initiative ensures the team will have proper support, resources, and protected time to accomplish the work.
What steps should we take to be compassionate to team members personally impacted by diabetes?
Be sensitive to the possibility that your team members may be struggling with diabetes themselves. Some members of your team likely have firsthand experience with diabetes or prediabetes, either personally or because a family member has the disease. Many might not even be aware that they have prediabetes or that there is something they can do to prevent progressing to a diagnosis of diabetes.

STEP 2 Evaluate How Patients' Poor Glycemic Control Impacts Your Practice

First, discuss the overarching impact of poor glycemic control among patients with type 2 diabetes on the clinic. Ask each team member to identify the negative consequences of poor glycemic control and the benefits of improving it. Make a list and ensure that every team member's perspective is included.

The list of consequences for the clinic may include:

Disrupted or delayed schedules because of frequent unplanned or prolonged patient visits
Extended hours or late nights to complete EHR inbox work because of numerous interruptions and calls from the emergency department, the pharmacy, and/or patients
More complex and time-consuming medication reconciliation
Potentially reduced income for the practice under new payment models
Lower patient satisfaction and negative experience as patients wait for their delayed appointment

Next, get granular to understand your patient population better. Analyze your practice data to determine how many patients have type 2 diabetes and/or prediabetes. One place to start is your patient care registry. Another starting point is a report from your IT or billing team. Ask your colleagues to pull data on all patients with type 2 diabetes or prediabetes by ICD-10 code. You can filter by age group as well. Share the report with your team.

Once you have the general report, further refine your list. Choosing a group of patients relevant to your practice that you can evaluate with baseline data is important, then applying an intervention and remeasuring. For example, identify the percentage of patients with diabetes who have poor glycemic control by selecting an HbA_1C (A_1C) cutoff. Some organizations focus on those patients with an A_1C greater than 9%, a group of patients referred to as “diabetic 9s.” Depending on the number of patients identified, you may decide to choose a smaller group by changing the cutoff. Parameters to narrow down to a more manageable number of patients include age ranges combined with A_1C measures (Figure 1). Limiting the age range may also yield a smaller population.

Generally, team members are surprised at the number of patients who have poor glycemic control, are not being seen in clinic frequently enough, or have not had blood tests drawn.

Figure 1. Sample Parameters for Identifying Subgroups of Patients for Targeted Interventions*

*These example parameters are based on A_1C levels put forth by the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association (ADA).⁵^,7

Applying these parameters, you may identify 100 patients in the practice who are 40 to 50 years old with A_1C between 8% and 10%. As a team, discuss these patients' needs and what interventions are simple and easy to implement. Can the care team manage this many patients, or must the parameters be adjusted?

Q&A

So many of my patients have diabetes or prediabetes, and the group size is overwhelming. What else can I do to make the number more manageable for my team?
Your team and resources will determine the optimal patient group size to focus on. If this is your team's first attempt at analyzing your patient population, be sure that the list of patients is manageable and that the work can be easily accomplished in a reasonable timeframe.
If the report you've generated using some of the parameters outlined in Figure 1 still includes too many patients for your initial project, further narrow the age range (eg, 50 to 60 years).
Other ways to filter to the ideal group size include a combination of pertinent factors and clinical characteristics, such as:
- 40 to 50 years of age with type 2 diabetes and no A_1C test in the past 7 months**
- 40 to 65 years of age with A_1C greater than 10% who have not been seen in the past 7 months
- 30 to 50 years of age with normal kidney function who are not taking metformin
- 40 to 50 with prediabetes and an A_1C between 6.0% and 6.4% who have not received a preventive intervention
**To avoid overscreening or repeat screenings, you want to establish a follow-up window longer than the recommended screening interval. For example, if prediabetes screening is recommended every 6 months, schedule subsequent visits within 7 months. Sometimes this concept is easier to articulate with annual screening. Follow-up visits for an annual, or every 12 months, depression screen should be set for within the next 15 months to avoid screening more than once per year.

STEP 3 Choose 1 Aspect of Diabetes Care to Address First

Patients with diabetes often have comorbid conditions and psychosocial factors that impair their ability to achieve and maintain optimal glycemic levels. To ensure that the care team does not become overwhelmed, steer them toward a small, targeted initiative that will likely succeed. Once your team develops the skills needed to succeed with 1 simple change, they will probably feel more confident and enthusiastic about taking on a more complex challenge.

For some practices, a process to standardize diabetes education is a logical first step. Look to see how many of your patients with prediabetes or diabetes who meet your predetermined criteria have had an order placed for diabetes self-management education services (DSMES). You might be surprised that only half of those patients had an order in place.

Your practice may also focus on 1 of the specific aspects of diabetes care and management, such as:

Screening for depression or early renal dysfunction
Performing foot exams
Implementing standing orders
Optimizing medications

Screening for Depression

People with diabetes are 2 to 3 times more likely to have depression than people without diabetes.⁸ A systematic review and meta-analysis found that approximately 20% of people with type 2 diabetes are depressed.⁹

Depression may coincide with diabetes distress, which may look like depression or anxiety on the surface but is distinct from these conditions. Diabetes distress can discourage and frustrate patients and may result in poor glycemic control or missed appointments.⁸

Routine screening for depression and referral for additional care (if warranted) may improve health outcomes for these patients and contribute to better diabetes self-care.¹⁰ Evidence suggests that a variety of interventions for depression (eg, pharmacologic therapy, collaborative care, psychotherapy, etc.) can have a significant impact on improving glycemic control.¹¹

Screening for Early Renal Dysfunction

Approximately 1 in 3 adults with diabetes have chronic kidney disease (or diabetic kidney disease); therefore, monitoring renal function and screening for albuminuria is important in these patients.¹²^,13 Diabetic kidney disease may be discovered simultaneously with a diagnosis of type 2 diabetes.¹³ Assessing renal dysfunction can be a relatively straightforward area for improvement. Start by incorporating pre-visit planning and standing orders to determine the urine albumin-creatinine ratio (uACR) for each patient with diabetes every year.

Performing Foot Exams

People with type 2 diabetes for more than 10 years are at greater risk of diabetic foot ulcers, but this complication can manifest in any patient.¹⁴

A basic but careful examination of both feet is essential to identify and treat foot ulcers early. Perform and document the foot exam at each visit. During an annual exam, perform a more thorough foot evaluation of pulse, sensation, structure and function, and nails.

Competency Assessment for Diabetic Foot Exam (322 KB)

Use this form to help train and assess care team members' competency to perform diabetic foot examinations.

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Ensuring patients with diabetes remove footwear should be a standard component of the rooming process and flagged during pre-visit planning or the care team huddle before the clinic day starts. A sign in the exam room that reads, “If you have diabetes, please take off your shoes and socks,” can alert patients about this aspect of their exam.

Implementing Standing Orders for Diabetes Care and Management

Standing orders can make a dramatic difference in streamlining diabetes care and management. Discuss with your team:

What the standing order will cover
Who will identify the patient(s) the standing order applies to
Who will enter the standing order

Standing orders for patients with diabetes might include:

Screenings
Performing foot exams
Lab orders, such as for serum lipid testing or A_1C
Referrals for a dilated eye exam, diabetes education, etc.

Example of an Internal Medicine Policy and Procedure Model (315 KB)

Use this template to create your own standing orders.

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Optimizing Medications

While some patients with type 2 diabetes can control their blood glucose levels through diet and exercise, many will require medication. Considerations in glycemic control include healthy lifestyle behaviors, education, and support (see STEP 6), self-management, avoidance of clinical inertia, and social determinants of health (see STEP 8). Selecting the appropriate therapy for newly-diagnosed patients is only one component of optimizing medications.¹⁵Medication management (including reconciliation, checking for prior authorizations, and evaluating adherence) and annual prescription renewals are also crucial for patients with type 2 diabetes.

Figure 2. What Are Annual and Synchronized Prescription Renewals?

Ideally, both annual prescription renewals and synchronized renewals occur, resulting in annual synchronized prescription renewal, which saves significant time for physicians and costs for practices (Figure 2).¹⁶^,18 Synchronize prescriptions (90 days x 4 refills, or 90 x 4 in shorthand) for medications to treat diabetes or hypertension as part of a patient's annual visit along with their comprehensive foot exam.

Do not neglect to educate patients about expected side effects or other considerations, as this can lead to nonadherence and suboptimal outcomes (See STEPS 6 and 7).

No one ever told me that the diarrhea from metformin would go away if I kept using the medicine. Now that I take it every day, I have no problem. But if I miss it for 3 days, the diarrhea comes back. That keeps me from forgetting to take my pills!”
—A patient with diabetes

Pre-visit planning, leveraging the patient portal, and an expanded rooming and discharge process are fundamentals of team-based care to involve patients, save time, and accomplish more during your clinic day. Engage patients in the medication reconciliation process and shared decision-making to tailor their treatment before they enter the exam room—either by sharing a questionnaire through the patient portal or with a paper handout to review in the waiting room. Setting the agenda can also be accomplished through the patient portal or with a form at check-in.

Help Us Plan Your Visit (Word) (145 KB)

Print this form and use it to engage patients in the medication reconciliation process and set the visit agenda.

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Q&A

How can I add a depression screen without taking time away from other elements of the visit?
Depression screening can be easily added to your practice workflow. Proactively identify the patients you want to screen for depression during pre-visit planning. Your team can ask these patients to fill out a depression screening assessment, for example, the Patient Health Questionnaire 9 (PHQ 9) or the PHQ 2 as appropriate, in the waiting room or exam room before you see them.
Which team members can perform the foot exam?
In some practices, the MA or nurse has the clinical training to examine feet properly for ulcers or injuries at every visit. The same individuals may also perform the annual diabetic foot exam, including annual microfilament testing for neuropathy. When patients see that the care team prioritizes the foot exam, they may be more likely to perform regular foot exams at home.
What if I have patients who are still not achieving their A1C goals?
If you have a patient who is not achieving their A_1C goal, first scan their medication list for drugs that promote weight gain, such as certain antidepressants, sulfonylureas, or steroids, and try to find a substitute.
Once you have reviewed the patient's medications for weight-promoting drugs, consider patient nonadherence to their medications. Medication nonadherence is high in patients with type 2 diabetes, and adherence is believed to be inversely related to HbA_1C level.¹⁹^,20 Often, patients hide not taking their medications as prescribed for fear of being admonished or disappointing their physician. Approaching patients in a nonjudgmental way to discuss adherence can yield important information about their medication-taking behavior. Recognize that social determinants of health may be barriers to adherence, and work with patients to address them (see STEP 8). Also, consider novel ideas like handing out a weekly pill organizer box to help patients be more adherent to your recommendations.
Your patient may also have undesirable side effects such as weight gain or an upset stomach. This information can help you adjust the treatment plan, so your patient can successfully manage their diabetes.
What is the best way to ask patients about their adherence to medications?
Patients may not feel comfortable being truthful if they sense their physician may judge them. Instead of saying, “Did you take your metformin as prescribed?” say, “Everyone forgets to take their medication sometimes. How often would you say you forgot your metformin in the last week?”
Many patients tell me they cannot tolerate metformin because of diarrhea. How can I help them?
Metformin is one of the most commonly used and familiar treatments for type 2 diabetes because it is safe, effective, and inexpensive.¹⁵ Many patients develop diarrhea upon initiation of metformin, which usually resolves within a week of continued use. The “start low and go slow” approach could minimize side effects and promote adherence.¹⁵ Explain to patients that the more consistently they take their medication, the more likely diarrhea will resolve. Surprisingly, if a patient misses their metformin for as few as 2 days, diarrhea will return once restarted. Preparing patients for this potential side effect and describing how you will help them manage it could also encourage adherence.

STEP 4 Choose 1 Aspect of Prediabetes Care to Address

More than 1 in 3 US adults have prediabetes (blood sugar higher than normal but not high enough to be diagnosed as type 2 diabetes).²¹ The US Preventive Services Task Force (USPSTF) recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who are in the overweight or obesity range.²² Physicians and care teams play an integral role in preventing or delaying type 2 diabetes in at-risk adults by offering or referring to effective preventive interventions.

Consider starting with 1 of the following processes:

Identifying more at-risk patients with a prediabetes screening program
Educating and creating urgency to address prediabetes
Referring patients to a National Diabetes Prevention Program
Improving monitoring and follow up

JAMA Patient Page: Screening for Prediabetes and Type 2 Diabetes (133 KB)

Overview of prediabetes and type 2 diabetes.

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Identifying More At-Risk Patients With a Prediabetes Screening Program

You can proactively identify patients at risk of prediabetes before a visit with a screening test and arrange for pre-visit lab testing ahead of a planned care appointment. This will allow face-to-face engagement with the patient about the results during the visit. Ask patients to complete an online risk assessment before their visit or share a diabetes risk test during rooming.

Prediabetes Risk Test (English version) (247 KB)

Use this English-language form from the National Diabetes Prevention Program to screen at-risk patients.

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Prediabetes Risk Test (Spanish version) (210 KB)

Use this Spanish-language form from the National Diabetes Prevention Program to screen at-risk patients.

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Educate your care team on the risk factors for prediabetes and think about creating standing orders to facilitate more frequent screening. Risk factors include²¹:

Being overweight
Being 45 years or older
Having a parent or sibling with type 2 diabetes
Being physically active less than 3 times a week
Ever having gestational diabetes or giving birth to a baby who weighed more than 9 pounds
Having polycystic ovary syndrome

Race and ethnicity are also factors: African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans are at higher risk. People with a history of cardiovascular disease or hypertension are also candidates for prediabetes screening.²¹^,23

Your EHR can run reports and/or make registries to capture these patients. Once patients are identified, order the appropriate lab tests, then if applicable, make the diagnosis and document appropriately. Standing orders may be valuable in this situation.

Prediabetes identification and management protocols (183 KB)

Follow this stepwise approach for physicians and care teams to identify and manage patients with prediabetes.

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Codes: When screening for prediabetes and diabetes (135 KB)

Find relevant ICD 10 and CPT codes for diabetes prevention to document diagnoses in the medical record and for billing.

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Creating Urgency to Address Prediabetes

Determine the best way to reach your audience. Increasing awareness of prediabetes is the first step to diabetes prevention. You can use the existing resources in the AMA Diabetes Prevention toolkit to promote prediabetes awareness to the care team and your patients. For example, print copies of the “Prediabetes: are you at risk?” handout to leave in the waiting room or other high-traffic areas to catch attention.

The Ad Council has social media resources and digital assets for you to use in your practice. For example, share a post about prediabetes on the practice's website or Facebook page. Or, if you have TVs in your waiting room, you could show a brief video about prediabetes risk in English or Spanish.

Assets for your practice:

Do I have prediabetes? social media kit from the Ad Council and the Centers for Disease Control and Prevention (CDC)
Type 2 diabetes prevention campaign assets from the Ad Council, the CDC, and the AMA

Prediabetes: Are you at risk? (English) (787 KB)

Use this English-language handout to draw attention to the prevalence and associated risk factors for patients.

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Prediabetes: Are you at risk? (Spanish) (830 KB)

Use this Spanish-language handout to draw attention to the prevalence and associated risk factors for patients.

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Inform your newly-diagnosed patients with prediabetes about the potential for future complications. It's important to highlight that prediabetes is treatable and can be reversible. You might consider saying, “Your blood sugar is higher than normal, but not at the level of diabetes. We call this prediabetes. Prediabetes is serious because it increases your risk for type 2 diabetes. Prediabetes can also double your chances of heart disease or stroke. The good news is that prediabetes is reversible. You can do things now to prevent prediabetes from becoming diabetes.”

Referring Patients to a National Diabetes Prevention Program

The National Diabetes Prevention Program (National DPP) is a research-based program that offers

evidence-based, cost-effective interventions to prevent type 2 diabetes, with an emphasis on lifestyle change programming. Structured lifestyle change programs for people with prediabetes were shown to reduce the risk of type 2 diabetes by 58%.²⁴ If the patient is interested and ready to make healthy lifestyle changes, refer them to an in-person or online National DPP lifestyle change program at a CDC-recognized organization.

Lifestyle Change Program Referral Template (44 KB)

Use this template as a guide for creating a form to refer eligible patients to a National DPP lifestyle change program.

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Patients are more likely to choose a treatment option if given a menu of choices. If there is no diabetes prevention program available or the patient declines the referral, use shared decision-making (see STEP 7) to find an alternative treatment, such as medical nutrition therapy or a prescription for metformin.

Despite high-quality evidence of efficacy and safety, metformin for prediabetes treatment is a non-FDA-approved (off label) use of this medication

Improving Monitoring and Follow Up

The physician's role is to monitor and support patients with prediabetes. This includes ensuring the patient is adhering to treatment, determining if treatment is effective, and monitoring for progression to diabetes with annual labs. Consider tracking your practice's monitoring and follow-up efforts with a patient care registry.

Q&A

What are the features of the National DPP lifestyle change program?
The National DPP lifestyle change program is designed to help patients with prediabetes modify behaviors, increase physical activity, promote healthy eating, manage stress, and stay motivated.²⁵
Some of the features are²⁵:
- A structured, year-long program of at least 16 core sessions in the first 6 months, followed by monthly sessions for the next 6 months
- Facilitation by a trained lifestyle coach in a group format that offers peer-to-peer support Programs are offered in many locations across the country
What is the evidence behind the National DPP lifestyle change program?
There was a 58% reduction in the number of new cases of diabetes overall and a 71% reduction in new cases for those over age 60 among initial participants in the Diabetes Prevention Program (DPP) clinical trial funded by the National Institutes of Health.²⁶ Researchers published the findings in the February 7, 2002, New England Journal of Medicine issue.²⁷ Additional 10-, 15-, and 21-year follow-up studies showing the effectiveness of the DPP have since been published.²⁶
What does insurance coverage for the National DPP look like?
Medicare, Medicaid, and commercial payers have varying degrees of coverage.
- Medicare DPP (MDPP): The MDPP expanded model allowed Medicare beneficiaries to access the evidence-based diabetes prevention program. The Centers for Medicare & Medicaid Services (CMS) has an interactive map of MDPP suppliers to help you find one in your area.
- Medicaid: 22 states and Washington DC offer coverage, although the degree of coverage may differ by state.
- Commercial payers: Most commercial health plans cover intensive lifestyle interventions. Your patient can check with their insurer or employer to see if they have coverage.
Does metformin prevent diabetes in at-risk adults?
Metformin has the strongest evidence base and demonstrated long-term safety for diabetes prevention.⁶ Although metformin is less effective than lifestyle modification for diabetes prevention in many patients, the DPP study found that metformin can reduce the risk of developing diabetes by 31% over 3 years.²⁷ Lifestyle modification with diet and exercise is approximately twice as effective as metformin for preventing diabetes, especially in older patients. Metformin was shown to be most effective in preventing or delaying the development of type 2 diabetes in younger, heavier people with prediabetes.²⁷ Metformin was also effective in lowering the risk of diabetes in women who have had gestational diabetes.²⁸ Clinical guidelines recommend that metformin can be considered for diabetes prevention in people younger than 60 years who are at very high risk for progressing to diabetes, such as women with a history of gestational diabetes or individuals with obesity class 2 or 3.⁶
How do I get a diabetes prevention program in my community?
First, check the DPP Find a Program website to find existing locations. For communities without a current program, physicians and members of their care teams can advocate for community organizations or their health system to offer the National Diabetes Prevention Program lifestyle change program. You may want to speak with the director of your local YMCA, hospital, state health department, or other interested community organization about the need to address prediabetes locally and encourage them to offer in-person or virtual diabetes prevention programming. Use these tools to make the business case for preventing prediabetes from turning into diabetes.
Note: Anyone establishing a diabetes prevention program must follow the CDC's evidence-based curriculum to become a CDC recognized provider.

STEP 5 Pilot an Intervention With Your Team

Improving diabetes management in your practice is an excellent opportunity for your team to learn about quality improvement (QI) strategies while positively impacting your patient population. The Plan-Do-Study-Act (PDSA) cycle is a commonly-used methodology for QI projects.

Your team can use a PDSA cycle to conduct small tests of specific change—doing a process slightly differently and then observing the results. If this is your team's first time engaging in a QI project, they must understand how a PDSA cycle works. You will also want to ensure that your team chooses an intervention that is simple, sustainable, and achievable. Table 1 describes some starter improvement projects that address aspects of diabetes care you may have selected in STEPS 3 and 4.

PDSA Activities for Prediabetes and Type 2 Diabetes Screening and Management (416 KB)

Use this tool to guide you through diabetes management QI activities following the Plan-Do-Study-Act (PDSA) methodology.

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Post tick charts where all team members can see progress as you advance in your improvement projects. Tick charts are clear visuals that help people quickly see the impact of the QI effort.

Tick or Run Chart Examples (368 KB)

Use these examples to help your team chart and visualize progress.

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Table 1. Examples of Diabetes or Prediabetes Quality Improvement Efforts to Test With PDSA

QUALITY IMPROVEMENT (QI) PROJECT GOAL	EXAMPLE OF INTERVENTION TO TEST WITH PDSA
Increase the percentage of patients with type 2 diabetes referred for diabetes education annually by 10%	Create standing orders for diabetes education referrals
Screen 80% of patients with type 2 diabetes for depression	Implement a depression screening process with a standardized questionnaire
Improve the frequency of foot exams to reach 100% of the population with type 2 diabetes	Ask all patients with type 2 diabetes to remove footwear at every visit during rooming
Decrease the percentage of patients with diabetes and obesity who are taking a medication associated with weight gain by 70%	Review chart to consider substitute medication
Increase the percentage of patients with an A_1C measurement in the past 6 months by 30%	Call the patient to schedule an appointment and order A_1C before their next visit as part of pre-visit planning
Increase referrals of patients with prediabetes to the National DPP lifestyle change program by 50%	Engage your care team with presentations and information on how to refer to the National DPP lifestyle change program

If the results from a QI project do not yield the desired outcome, reflect on why while acknowledging the effort and teamwork that went into planning and carrying out the initiative. Celebrate and reward the hard work of trying something new. Then, as a team, continue to work together to repeat the PDSA cycle with different small tests of change until the desired result is achieved.

For any prediabetes intervention you pilot, your team should review the number of patients with prediabetes who have not progressed to diabetes as an annual metric and any metrics specific to the intervention.

Don't neglect to reward your team for creative responses encouraging patients to eat better and exercise. Some organizations celebrate the team, their patients, and the community with a special day. They invite patients to a vacant parking lot or park for booths, food trucks serving nutritional food, and short races or physical activities to promote movement. Celebrations like this show patients they are not alone with this chronic disease; it is an opportunity to see how others manage it. Your practice or organization may also consider sponsoring or participating as a team in a walk-a-thon, fun run, health fair, or other community event.

Ways to Celebrate Your Team's Success (329 KB)

Use this document for some ideas on how to celebrate your QI efforts.

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STEP 6 Support Your Patients With Education

Education is paramount for all patients with prediabetes or type 2 diabetes. Patients must understand how to monitor and manage their condition at home to reach their glycemic goals and avoid preventable complications.

Start by:

Helping patients understand their numbers
Providing lifestyle education (as a supplement to participation in a National DPP lifestyle program if the patient has prediabetes)

Helping Your Patients Understand Their Numbers

Help your patients understand the purpose of the A_1C test. Explain in simple language that the A_1C test measures the average blood sugar level in the body over the previous 3 months.²⁹ Patients may also want to know what fasting blood sugar is, how a glucose tolerance test works, and what their test results mean. Showing patients an image or handout listing typical test results and corresponding diagnoses is helpful (Figure 3).

Elements of helping patients understand their numbers could include explaining how to read their after-visit summary or making sure they know that visit notes and more information are available to them in the patient portal. Adapting your documentation style to create transparent shared clinical notes can go a long way in engaging and reaching patients to participate actively in their health care.

Figure 3. Example of Patient Education Material Explaining Diabetes Test Results²⁹

Road to Diabetes Infographic (CDC) (PDF) (483 KB)

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Your patient's A_1C goals will depend on their personal needs. Shared decision-making towards an A_1C goal and a plan for achieving this goal can help patients maintain overall health and minimize diabetes-related complications (See STEP 7 for more on shared decision-making).

How to Manage Blood Sugar (248 KB)

Use this handout to educate patients on managing blood sugar

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Providing Lifestyle Education

Good nutrition and physical activity are crucial for achieving A_1C targets for patients with type 2 diabetes and essential for patients with prediabetes to delay or prevent progression to type 2 diabetes.

Share educational resources with your patients such as:

Living With Diabetes resources from the CDC
4 Steps to Manage Your Diabetes for Life from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Tips for healthy living, including nutrition, weight loss, and fitness, from the American Diabetes Association

So, you have prediabetes … now what? (646 KB)

Use this English-language handout to help patients diagnosed with prediabetes take preventive measures.

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Entonces, usted tiene prediabetes… ¿y ahora qué? (830 KB)

Use this Spanish language handout to help patients diagnosed with prediabetes take preventive measures.

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Managing diabetes: steps to help you stay healthy with diabetes (671 KB)

Use this handout to help patients diagnosed with type 2 diabetes follow a healthy lifestyle.

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You can give this list of resources to patients to take home or add it as a template to the electronic health record as part of your after-visit summary.

A team member with experience using tools for diabetes or weight management can be an asset as they become your local expert on these subjects. This team member could fulfill a formal health coaching role or act as a diabetes care and education specialist. Such expertise increases team engagement and helps team members better understand the challenges patients face in reaching a healthy weight and glycemic control.

Some patients may also benefit from referrals to diabetes self-management education and support (DSMES) services. Deconditioned or sedentary patients could be referred to physical therapy, which often helps them build confidence to get moving again.

For some patients, education takes place in the exam room. Take the opportunity to talk about reducing calories by reducing their intake of high-calorie beverages. A recent meta-analysis found that reducing sugar intake by about 6 teaspoons per day or limiting to 1 sugar-sweetened beverage per week decreased the adverse effect of sugar on health.³⁰ Sharing clear examples with your patients is helpful, and a simple, impactful visual aid teaches patients about the caloric content of drinks. To create this visual aid, add granulated sugar to an empty soda bottle in an amount equivalent to the sugar content of soda. As an estimate, a 20-ounce bottle of soda contains about 16 teaspoons of sugar. Place a bottle in each exam room. Patients often pick up the bottle without being prompted and are very surprised to see the amount of sugar contained in soda. Tell them that consuming 1 fewer 20-ounce soda (approximately 225 calories) a day could result in weight loss of half a pound per week or 25 pounds in 1 year. Most patients agree to try this simple dietary change.

Help patients develop healthy habits at home. Educate them about footwear that can help prevent foot wounds, such as special shoes or inserts. Many patients are unaware that Medicare Part B may cover part of the cost of these items. Share tips for foot self-exams and care. A health coach or trained MA can have these conversations with patients.

Take Charge of Your Diabetes: Healthy Feet (476 KB)

Hand out or include a link to this guide in the patient portal to help patients develop good foot care habits.

View All Downloadable Resources

Tips for Healthy Feet (458 KB)

Display, hand out, or include a link to this infographic in the patient portal to help patients take better care of their feet.

View All Downloadable Resources

Q&A

How can I help my patients understand the connection between the glucose monitor or glucose meter results they see at home and their laboratory A1C results?
First, remind them that the A_1C measures the average blood sugar level over the last 3 months. The A_1C reflects all the ups and downs of blood sugar levels over time and gives the big picture of how well treatment or lifestyle changes are working to control blood sugar.³¹
Sometimes, A_1C results are described as estimated average glucose or eAG. Unlike A_1C, which is reported as a percent, the eAG is in the same units of measure (mg/dL) as a moment-in-time measure from a home blood glucose monitor.³¹
You could share a conversion table to help put home readings into context with laboratory results (Table 2). Remind patients that eAG is often higher than what they may see when they take a reading because it is an average covering time when people tend not to check their blood sugar, such as right after a meal when they know it will be higher.³¹ Graphic Jump Location
How can we encourage our patients to exercise?
First, consider your wording for discussing physical activity with your patients. “Exercise” may sound intimidating to those who equate the word with a full workout, which isn't always necessary or feasible. The most important message to send patients is to move more and sit less, so consider using phrases like “physical activity” instead of “exercise” when talking with patients.
Encourage patients to exercise in short blocks if that works best for them. A daily calendar, step counter, or activity tracker can motivate some patients. They should aim for 150 minutes of moderate intensity activity each week, but how they get there is up to them. According to the CDC, examples of moderate intensity activity include:
- Mowing the lawn
- Dancing
- Swimming
- Doing housework
- Walking
What are some diagnosis codes for physical therapy referrals?
Appropriate diagnosis codes for a referral may include:
- Deconditioning
- Generalized weakness
- Unsteady on feet
- Difficulty in walking
- Poor balance
- Osteoarthritis
- Abnormality of gait
How big of a problem are diabetic foot ulcers?
Foot ulcers occur in up to 25% of patients with diabetes.³² Many people with diabetes—about 60%—develop neuropathy.³² Half of the people with neuropathy do not have symptoms, so it is crucial for the care team to check areas where a patient does not have feeling for scratches, wounds, or other injuries that may worsen with time.³³ Patients are often unaware of foot wounds due to impaired sensation caused by diabetic neuropathy. Education about good foot health is imperative for patients with type 2 diabetes.

STEP 7 Use Shared Decision-Making to Develop Treatment Plans

Patients are more likely to adhere to their treatment plan if they help design it. Start by:

Using decision aids to evaluate treatment options
Employing the teach-back technique
Asking, “What questions do you have for me?” at the end of every visit

Using Decision Aids to Evaluate Treatment Options

Because some drugs promote weight gain, reviewing patients' medication lists and replacing these drugs, if possible, is important. Mayo Clinic created an interactive Diabetes Medication Choice decision aid to help you and your patients evaluate available medications; the decision aid is available in English and Spanish. Check clinical practice guidelines for medication recommendations, as these frequently change.

5 Questions to Ask Your Health Care Team (557 KB)

Give this guide to patients to help them ask questions that will help them manage their diabetes.

View All Downloadable Resources

Employing Teach-Back Techniques

Use the teach-back method to check that your patient understands their treatment plan. Ask that they repeat back to you the plan you've just discussed.

Teach-Back (Closing the Loop) (397 KB)

Use this tool to ensure patients understand their care plan before they leave the practice.

View All Downloadable Resources

Asking, “What Questions Do You Have for Me?” at the End of Every Visit

As you conclude a visit, ask the patient, “What questions do you have for me?” rather than “Do you have any questions?” This slight rephrasing turns a question that would prompt a yes or no response into an open-ended question. Open-ended questions allow patients to ask about any last-minute concerns or areas of confusion.

Responding to these questions during the visit will save time in the long run and improve patient care by correcting any misunderstandings about medications or the treatment plan.

Q&A

What is shared decision-making?
Shared decision-making is a process in which patients share their values and preferences, and clinicians share the best clinical evidence available to arrive at a decision regarding a test or treatment consistent with outcomes that matter most to the patient.³⁴ Shared decision-making, including empathetic conversations between patients and clinicians, is essential for person-centered care. Determining the best management plan for a patient requires a consideration of each individual's personal, social, and biomedical context; the patient's values and how these values relate to the available options; and the benefits, harms, cost, and inconvenience of each option.

STEP 8 Screen for Social Determinants of Health and Commit to Advancing Health Equity

A growing body of evidence points to the influence of social determinants of health (SDOH) factors on health outcomes. SDOH factors impact the prevention and management of type 2 diabetes for many people.³⁵

Food insecurity and low diet quality are associated with suboptimal glycemic control.³⁶ Food affordability influences purchasing decisions and, subsequently, diet quality.³⁷ Other evidence shows that those with lower socioeconomic status (occupation, education, and income) are more likely to develop type 2 diabetes and experience more complications.³⁷ Adding screening for SDOH to the tactics outlined earlier in this toolkit can help you improve population health in your practice. By incorporating screening into your workflow, you will quickly understand what is important to the patient and identify social determinants impacting their health status. Here are examples of some free screening tools:

PRAPARE—Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences Implementation and Action Toolkit
SIREN—Social Interventions Research and Evaluation Network
The EveryONE Project™ (PDF)—Developed by the American Academy of Family Physicians (AAFP)
AHCM (PDF)—Accountable Health Communities Health Related Social Needs Screening Tool

After the screening, connect patients to resources and community organizations, or offer a referral to a social worker. Examples of resource connections might include:

Referrals to local food banks and food pharmacies
Vouchers for bus and subway transportation
Providing a mobile food pantry at a clinic location

Take advantage of the 211—Essential Community Services Program. By simply dialing “211,” callers are routed to referral specialists who can match them to available resources and oftentimes will make a direct referral to an organization that can provide assistance. This resource is available throughout the US.

Addressing SDOH is a component of the broader goal of advancing health equity. To learn more about how your practice or organization can turn a commitment to racial and health equity into action, see these 2 related STEPS Forward^® toolkits:

Conclusion

Patients with type 2 diabetes or prediabetes often have numerous other chronic conditions, which can make improving the health (and measurable outcomes such as A_1C) of these patients very challenging. It is important to take small, simple steps and engage your team in a way that results in long-lasting change. Avoid frustration by approaching the challenge with your team and choosing interventions likely to result in success. Also, always remember to celebrate your patient's health achievements, the care team's dedication to working together to improve patient care, and your overall practice improvements.

AMA Pearls

Start with small, acheivable goals for your first improvement projects.

Make sure to celebrate your team's decision to take on a change project, as well as any improvements in outcomes as a result of their work.

Resources

Competency Assessment for Diabetic Foot Exam (322 KB)

Use this form to help train and assess care team members' competency to perform diabetic foot examinations.

View All Downloadable Resources

Example of an Internal Medicine Policy and Procedure Model (315 KB)

Use this template to create your own standing orders.

View All Downloadable Resources

Help Us Plan Your Visit (Word) (145 KB)

Print this form and use it to engage patients in the medication reconciliation process and set the visit agenda.

View All Downloadable Resources

JAMA Patient Page: Screening for Prediabetes and Type 2 Diabetes (133 KB)

Overview of prediabetes and type 2 diabetes.

View All Downloadable Resources

Prediabetes Risk Test (English version) (247 KB)

Use this English-language form from the National Diabetes Prevention Program to screen at-risk patients.

View All Downloadable Resources

Prediabetes Risk Test (Spanish version) (210 KB)

Use this Spanish-language form from the National Diabetes Prevention Program to screen at-risk patients.

View All Downloadable Resources

Prediabetes identification and management protocols (183 KB)

Follow this stepwise approach for physicians and care teams to identify and manage patients with prediabetes.

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Codes: When screening for prediabetes and diabetes (135 KB)

Find relevant ICD 10 and CPT codes for diabetes prevention to document diagnoses in the medical record and for billing.

View All Downloadable Resources

Lifestyle Change Program Referral Template (44 KB)

Use this template as a guide for creating a form to refer eligible patients to a National DPP lifestyle change program.

View All Downloadable Resources

PDSA Activities for Prediabetes and Type 2 Diabetes Screening and Management (416 KB)

Use this tool to guide you through diabetes management QI activities following the Plan-Do-Study-Act (PDSA) methodology.

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Tick or Run Chart Examples (368 KB)

Use these examples to help your team chart and visualize progress.

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Ways to Celebrate Your Team's Success (329 KB)

Use this document for some ideas on how to celebrate your QI efforts.

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Road to Diabetes Infographic (CDC) (PDF) (483 KB)

View All Downloadable Resources

How to Manage Blood Sugar (248 KB)

Use this handout to educate patients on managing blood sugar

View All Downloadable Resources

So, you have prediabetes … now what? (646 KB)

Use this English-language handout to help patients diagnosed with prediabetes take preventive measures.

View All Downloadable Resources

Entonces, usted tiene prediabetes… ¿y ahora qué? (830 KB)

Use this Spanish language handout to help patients diagnosed with prediabetes take preventive measures.

View All Downloadable Resources

Managing diabetes: steps to help you stay healthy with diabetes (671 KB)

Use this handout to help patients diagnosed with type 2 diabetes follow a healthy lifestyle.

View All Downloadable Resources

Take Charge of Your Diabetes: Healthy Feet (476 KB)

Hand out or include a link to this guide in the patient portal to help patients develop good foot care habits.

View All Downloadable Resources

Tips for Healthy Feet (458 KB)

Display, hand out, or include a link to this infographic in the patient portal to help patients take better care of their feet.

View All Downloadable Resources

5 Questions to Ask Your Health Care Team (557 KB)

Give this guide to patients to help them ask questions that will help them manage their diabetes.

View All Downloadable Resources

Teach-Back (Closing the Loop) (397 KB)

Use this tool to ensure patients understand their care plan before they leave the practice.

View All Downloadable Resources

Additional Resources

(15 KB)

Prediabetes: Are you at risk? (English) (787 KB)

Use this English-language handout to draw attention to the prevalence and associated risk factors for patients.

View All Downloadable Resources

Prediabetes: Are you at risk? (Spanish) (830 KB)

Use this Spanish-language handout to draw attention to the prevalence and associated risk factors for patients.

View All Downloadable Resources

Article Information

Participation Statement: Upon completion of this activity, learners will receive a Participation Certificate.

Disclaimer

AMA STEPS Forward^® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward^® content provides information on commercial products, processes, and services for informational purposes only.

The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward^® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward^® content.

About the AMA Professional Satisfaction and Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group is committed to making the patient–physician relationship more valued than paperwork, technology an asset and not a burden, and physician burnout a thing of the past. We are focused on improving—and setting a positive future path for—the operational, financial, and technological aspects of a physician's practice. To learn more, visit stepsforward.org.

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Disclaimer: AMA STEPS Forward^® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward^® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward^® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward^® content.

Team-Based Care of Type 2 Diabetes and PrediabetesApproaches to Help Patients Reach Their Glycemic Goals

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