How will this module help me improve glycemic control and prevent complications in my patients with type 2 diabetes?
Outlines six steps for developing an efficient team-based approach to managing diabetes
Provides answers to common questions about diabetes management for patients with type 2 diabetes
Provides examples from other practices on how they are helping patients achieve their glycemic goals
Diabetes is a complex illness that requires a lot of effort to manage, by both patients and their care teams. The good news is that there are simple interventions that can make a big difference and save time. Successful management can be achieved by taking multiple small steps.
Six STEPS to develop an efficient team-based approach to managing diabetes
Engage your team
Evaluate the impact of poor glycemic control among patients on your practice
Choose one aspect of diabetes care to address first
Pilot an intervention with your team
Optimize medications
Engage your patients in their treatment plan
Quiz Ref IDQuiz Ref IDLead change by engaging the entire clinic team early on, including front desk staff, medical assistants, nurses, and other care providers. They will feel more involved in any improvement initiatives and more willing to help shape the approach to change. Consider having periodic meetings with team members so everyone is on the same page and to answer questions and address any issues that may arise. Communicate the importance of improving the management of type 2 diabetes for patients in your practice. Various resources are available that offer direction on how to best coordinate engagement among your team members. Consider inviting pharmacists, diabetes educators, nutritionists, administrators and patients to these meetings to help your team understand all aspects of diabetes
STEP 2 Evaluate the impact of poor glycemic control among patients on your practice
Analyze your practice data to determine how many of your patients have type 2 diabetes and the percentage that have poor glycemic control. To identify patients, work with your IT or billing staff to create a report listing all patients with type 2 diabetes by ICD10 code. Share the report with your team. Generally, staff 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. You can also increase your staff's knowledge of diabetes to better address the needs of patients with type 2 diabetes. A sample curriculum is provided for your convenience.Next, shift the focus toward the impact of poor glycemic control among patients with type 2 diabetes on the clinic itself. Ask each team member to identify the negative consequences of poor glycemic control and the benefits of improving glycemic control. Make a list and ensure that every team member's perspective is included. The list of consequences may include:
Disruption of the schedule because of frequent unplanned or prolonged visits
Delays in the schedule and a full waiting room because of prolonged visits
Finishing work late because of numerous interruptions and extra calls from the emergency room, the pharmacy and patients
Potentially lower income for the practice under new payment models
STEP 3 Choose one aspect of diabetes care to address first
Patients with diabetes often have a number of comorbid conditions and psychosocial factors that impair their ability to achieve optimal glycemic levels. To ensure that the team does not become overwhelmed, steer team members toward choosing a small, targeted initiative that is likely to succeed. Once your team develops the skills needed to succeed with one simple change, they are likely to feel more confident and enthusiastic about taking on a more complex challenge.
Places to consider starting include:
STEP A Screen for depression
Depression affects nearly 1 in 10 patients with diabetes. There is evidence that depressive symptoms can affect physical symptoms related to glucose regulation because of poorer self-care.16 Therefore, effective treatment for depression in patients with diabetes may not only improve depressive symptoms and quality of life, but also indirectly improve disease outcomes and illness burden.4
STEP B Help your patients understand their numbers
STEP C Provide lifestyle education
Good nutrition and physical activity are important elements to achieving A1C targets for patients with type 2 diabetes. You can provide educational materials for patients, such as 4 Steps to Manage Diabetes for Life or the guide from the American College of Physicians, Living with Diabetes. A staff member with experience using tools for diabetes or weight management can also be an asset as they can become your local expert on these subjects. Such expertise increases staff engagement and helps staff members better understand the challenges that patients face in trying to achieve glycemic control and a healthy weight.
Providing clear examples to your patients is also helpful. This could include using a simple, impactful tool to teach patients about the caloric content of beverages. To create this tool, 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. Take the opportunity to talk about reducing calories by cutting back on their intake of high-calorie beverages. Let them know that consuming one less 20-ounce soda (approximately 225 calories) a day could potentially result in weight loss of a half a pound per week or 25 pounds in one year. Most patients agree to try this simple dietary change. Sharing this educational tool with patients can be a fun and simple intervention to try for your first quality improvement (QI) effort.
“I enjoyed the diabetes classes and had no idea there was so much sugar in soda, juices and sweet tea. I stopped drinking these one month ago and have lost three pounds already! I don't miss them at all and I have saved money!”
A patient newly diagnosed with diabetes
STEP D Screen for early renal dysfunction
Monitoring renal function and screening for microalbuminuria are important in patients with diabetes. The urine albumin-to-creatinine ratio (ACR) should be determined for each patient on an annual basis. Assessing renal dysfunction is a relatively straightforward area to improve on and can be addressed with pre-visit planning and standing orders. (Standing orders for patients with diabetes might also include serum lipid testing, referral for dilated eye exam, and referral for diabetes education).
STEP E Perform foot exams
Patient education about foot care and careful examination of both feet at each visit are important for the early identification and treatment of foot ulcers. Ensure that removal of patients' footwear is a regular component of the rooming process. Putting a sign in the exam room, such as one that reads, “If you have diabetes, please take off your shoes and socks,” can also help. Perform and document the foot exam at each visit.
It also is helpful to educate patients 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.
STEP 4 Pilot an intervention with your team
Improving diabetes management in your practice is a great opportunity for your team to learn about quality improvement (QI) strategies while making a positive impact on your patient population. A commonly used strategy for engaging in QI projects is the Plan-Do-Study-Act (PDSA) cycle.
Teams can use a PDSA cycle to conduct small tests of specific change—doing a process in a slightly different way and then observing the results. If this is the first time your team is engaging in a QI project, it is important they understand how a PDSA cycle works. You will also want to ensure that your team chooses an intervention that is simple, sustainable and achievable. See the following table for some simple improvement projects with which to start.
As you advance in your improvement projects, post simple tick chart's where all staff can see the progress being made (see examples and a downloadable chart for your team to use).
QI PROJECT GOAL | EXAMPLE OF INTERVENTION TO TEST WITH PDSA |
---|
Increase percentage of patients with whom your staff discusses high-calorie beverages | Place an empty soda bottle containing granulated sugar in each exam room |
Increase percentage of patients referred annually for diabetes education | Create standing orders for diabetes education referral |
Screen patients for depression | Implement depression screening questionnaire in waiting room or exam room |
Improve frequency of foot exam | Ensure that all patients remove footwear at every visit |
Decrease percentage of patients with diabetes and obesity who are taking a medication associated with weight gain | Review chart to consider substitute drug |
Increase percentage of patients with an A1C measurement in past 6 months | Call patient to schedule appointment and order A1C |
If the results from a QI project do not result in the chosen outcome, take time to reflect on why the outcome was not achieved while also acknowledging the 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.
STEP 5 Optimize medications
While some patients with type 2 diabetes can control their blood glucose levels through diet and exercise, many will require some form of medication. Because some drugs promote weight gain, it is important to review patients' medication lists and replace these drugs if possible.
“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
STEP 6 Engage your patients in their treatment plan
Patients are more likely to adhere to their treatment plan if they helped design it. Here are some tools that can help engage your patients:
The Mayo Clinic has developed decision aids to support shared decision-making conversations between clinicians and patients with diabetes about treatment options related to diabetes medication and statin therapy to reduce cardiovascular risk.
Quiz Ref IDUse 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.
STEP C “What questions do you have for me?”
At the conclusion of your visit, ask the patient, “What questions do you have for me?” rather than “Do you have any questions?” Using an open-ended question creates an opportunity for your patient 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.
STEP D Patient education tools
You can provide education tools that patients and their families can review at home. Here is a list of helpful resources for patients, including some engaging videos. 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.
Providing diabetes education (64 KB)
Patients with type 2 diabetes often have numerous other chronic conditions, which can make improving the health (and measurable outcomes such as A1C) of these patients very challenging. Avoid frustration by approaching the challenge with your team and choosing interventions that are likely to result in success. It is important to take small, simple steps and engage your team in a way that results in long-lasting change. Also, always remember to celebrate the success of your patient's health achievements, the care team's dedication to working together to improve patient care, and your overall practice improvements.
NIDDK: Know your blood sugar numbers
National Diabetes Education Program
National Diabetes Education Program Patient Fact Sheets
National Diabetes Education Program Toolkit