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08-22-2017 | Primary care | View from the clinic | Article

Five things you can do to make your diabetes visits more efficient

Author:
Jay Shubrook

Author bio | Disclosures

1. Set aside four visits per year for diabetes alone

Managing diabetes and other chronic diseases is hard. The current system is set up to manage acute problems and complaints. Our visits with patients are short, and reimbursement is largely based on volume and not quality. Many patients with type 2 diabetes are resistant to the idea of diabetes-specific visits. There are 8760 hours in a year, and diabetes is a serious chronic disease that warrants at least 1 hour of visits in total per year. If a patient has an acute complaint at the time of their visit then the focus can change to the patient’s concern; however, a new visit should then be scheduled to focus on their diabetes. There are often many things that need to be discussed during diabetes visits, including: a medication review and adherence check, a review of glucose logs and analysis of glucose patterns, cardiovascular risk reduction, preventative therapies (including vaccines), eye and dental appointments, nephropathy screening, and healthy living (eg, nutrition and exercise). One way to make sure that you get through all of these topics is to have staged visits with a particular focus.

2. Utilize a download station

Most providers encourage their patients to check their own glucose at home with a glucose meter and then to bring their meter or glucose log to the appointment to review the results. Often the data are collected for ease of the user, which makes sense from the standpoint of the patient; however, these data are also intended to help the provider to see glucose patterns and make treatment decisions. It is often hard for providers to make sense of or see patterns in glucose readings based on a daily schedule when they are toggling through a glucose meter or a long single-file list of readings. This also takes time, a premium that most providers do not have.

The solution is the glucose meter download station. Most commercially available meters have a cable and software that is free and enables providers to download data from the meter. The program can then display the data in a way that is much easier to interpret. With a quick glance, providers can see how often their patient is testing their glucose, if they are experiencing any hypoglycemia, and any general trends throughout the day or over time. In my office, the medical assistant collects the meter while checking the patient in and will download the data into their electronic medical record.

The location of your equipment can also be important; for example, in my practice we have two computers that are used for glucose meter downloads: one at my medical assistant's desk and one in a central place, like a procedure room, to allow a second download to be completed or to allow another person to download the data if my medical assistant is absent that day. Figure 1 shows an example of a typical glucose meter download.

3. Have a point-of-care HbA1c machine

Many patients and providers rely heavily on glycated hemoglobin (HbA1c) values to determine adequacy of care in diabetes. This value can be checked as often as every 3 months for ongoing management. Previously, this was only available by venipuncture, which required a second step: Get the lab before the appointment to allow for discussion of the results at the patient visit. To achieve this, the lab would need to be ordered in advance of the patient’s visit or, alternatively, during the appointment, thereby leaving you without access to the results during the face-to-face appointment, meaning you or your office staff would have to follow up with the results. Furthermore, this may have not been completed as it was often lumped in with fasting lab, which may delay or prevent the person from getting the labs completed due to schedule challenges, added inconvenience, or fear of hypoglycemia.

An in-office point-of-care HbA1c machine (Figure 2) allows you to get a finger-stick value in less than 6 minutes. This too can be completed by the medical assistant as the patient is checked in for their appointment. While this does require prescreening the chart to see who is in need of an HbA1c test, it allows for an immediate response that you control. All of which facilitates the real-time face-to-face conversation about the HbA1c and the finger-stick glucose readings from the patient’s glucose meter, giving you much richer data about the patient’s current glucose control.

In addition, you may even be able to earn a small profit from this practice. For example, in our clinic, we are able to bill for the point-of-care testing (as long as it has been 3 months since the last test) and earn a small margin from each test.

4. Celebrate patient victories/Meet the patient where they are at

Diabetes is managed largely by the patient, with 90–95% of all of diabetes care estimated to be self-management [1]. To be successful, people make many decisions every day to improve their health, sometimes in a family or community setting that is less supportive than it should be. The process of diabetes self-management is therefore a big deal. People often do all of the work required and still do not get the desired outcome. Life happens, and family, financial, and health stressors occur, which can affect glucose control.

So, when you are working with your patient, try to remember a few important things that can really help to support them. Meet them where they are at. We often start with the behaviors we want our patients to achieve. However, the path to this goal may be short for some and longer for others. So remember which applies to your patient and provide positive feedback if the patient is attempting this desired behavior, even if only a small amount of progress is made.

5. Remember cardiovascular disease

While most patients with diabetes worry about the microvascular complications, the number one cause of death is from cardiovascular (CV) disease [2]. When you ask a patient what scares them the most about diabetes you will typically hear things like “going blind,” “getting put on dialysis,” or “having an amputation.” These are all serious and real risks of long-standing diabetes, so this fear is valid. However, 84% of people with diabetes will die from a heart attack or stroke [2]. These real complications are not considered by many patients to be related to diabetes. Since CV disease is the biggest threat to patients with diabetes, time and attention should be focused on reducing a patient’s CV risk. One step providers take to minimize CV risk is to address the risk factors in order of their severity. While most doctors think about glucose lowering, this only has a secondary role in CV risk reduction [3]. Hypertension treatment, followed by lipid treatment with statins, provides more "bang for the buck" in terms of cardiovascular risk [4]. That is only to say: Remember to address all three items. Anytime you can use an agent that reduces blood pressure and glucose levels you could get even more benefit.

In summary, to make your diabetes visits more efficient, I recommend following the five steps listed below:

  1. Give diabetes four visits per year.
  2. Get a download station for glucose meters.
  3. Have a point-of-care HbA1c machine.
  4. Celebrate small patient victories.
  5. Remember to focus on CV disease.
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