Team Approach to Management of Type 2 Diabetes Mellitus


Published on

DALE Initiative Podcast Transcripts!

The embedded documents in each of the segments are the individual PDF transcripts of the DALE Initiative podcast segments for this course. These documents are the transcripts only. There are no slides or other graphic support included.

To access all the content for the DALE initiative and get CME/CE credit for free, go to and register for the course.

Download and Share

To download an PDF transcript, click the "Download" button located on the top of of each document. You can also share each transcript with your colleagues or embed them on any number of social networks and websites using the share icon link located on the top bar of the slideshare box.


For technical support, please e-mail

Published in: Education, Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Team Approach to Management of Type 2 Diabetes Mellitus

  1. 1.   PODCAST  TRANSCRIPT:   TEAM  APPROACH  Joel Zonszein, MD, CDE, FACE, FACP:The question is why do we need a team approach in managing patients with diabetes?Well, diabetes is a very complex disease. It is not just lowering blood sugars. It is much morethan that. It is providing a healthy diet, trying to motivate the patients to exercise. By the waywhen I say a healthy diet, I do not mean only caloric reductionI mean changing to less caloriesand making it healthier. So, less fat food, less simple carbohydrates, and those are easy thingsto do. Patients need to understand why we do that. I find in the Diabetes Self-ManagementEducational Classes that patients have a tremendous amount of interest in learning on howtoeat well. Even if we do this day in and day out, patients do not believe that when they buy agallon of orange juice or when they put fruits in the blender they are consuming an enormousamount of sugar.We have to explain that even in the orange juice,even when written on the label “no sugaradded”, the amount of sugar (simple carbohydrates), is not different from what we have in abottle of Coca-Cola or Pepsi Cola. So, they have to learn this. They sometimes have questionsthat the physicians cannot answer; we physicians don’t have a proper training in nutrition.Nutritionists are very good not only in their knowledge about food and different dietaryrecommendations, but also in how to overcome some of the barriers in changing the habits thatthese patients have for so many years. In our center, when we educate a patient in bettereating we want to make an impact on the entire family, not only in the patient. It is similar as insmoking cessation, if the partner of the person that wants to stop smoking also smokes, it isvery difficult; it is much easier when all in the household stop smoking.So, smoking cessation is not only for one individual; similarly changing into a better dietaryregimen is important not only for the patient but for the entire family; the person who goesshopping, the person who does the cooking, and again the entire family sitting at the table.These are somethings that havenot been emphasized until recently. Again, we want a healthierdiet not only in people who have diabetes, but also we want it in their children who are at veryhigh risk to develop diabetes because they do have a parent with diabetes. So, family changesare important.The person does not have to become a nutritionist, but needs to acquire basicknowledge about what type of foods to eat and how to prepare the food. We have been usingthe plate model that was recommended recently by the U.S. Department of Agriculture. Thenwe go to the other educators in the team, which are the registered nurses; they tend to be betterDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  2. 2.  than physicians in providing education and finding out some of the barriers we, physicians, oftenoverlook. Nurses are very good at explaining to the patient and finding what the barriers areand how to overcome those barriers. When the patient sees that there is a team of anutritionistand a nurse and a physician taking care of them and helping them, they appreciate that.When we deal with diabetes, we want to include all the healthcare providers in the team;including a pharmacist who will be discussing with the patient the importance of adherence, thedosage, the drug interaction.Asocial worker is also particularly important in the area where Iwork where patients have major social issues, they help arranging their finances for getting themedications, better housing, etc. Other specialist physicians are also part of the team. Noteverybody who has diabetes needs to see a podiatrist, but Podiatry care and education forprevention of foot complications are important, so podiatrists often become part of our team.We recommend that patients with type 1 diabetes start seeing the eye doctor five years afterdeveloping their disease because that is when complications may start to develop. We wantpatients who have type 2 diabetes to start seeing an ophthalmologist at least once a year sincethe diagnosis of the disease,to prevent and avoid retinopathy.So, the ophthalmologist, the podiatrist, the pharmacist, the social worker, the nurse, thenutritionist are all part of the team and unfortunatelythose patients who already have organdisease such as heart disease or kidney disease may need to see also a cardiologist or anephrologist. Again when we treat this complex disease called diabetes we need more of ateam approach to better help the patient. Having said that the person who is at the center of theteam is always the patient and what we try to do is to empower the patient and have the patienttake the initiative to continue to take care of themselves again through education and a teamapproach.Lenora Lorenzo, DNP, APRN, FNP/ADM: Another challenge in terms of medication is themedia. It has now published every known side effect to every medicine and patients get veryconfused and alarmed. Therefore when they do come in and we start them on a new medicationthat they heard about from TV, they may have preconceived ideas and they may report the sideeffects that nobody ever gets so it is a challenge to deal with that. I try to forewarn them and letthem know that there are common types of reactions that people may or may not have and thatthere are some that are very unlikely to happen, but that the media, to protect themselveslegally, will give them information. So, I try to get them to realize that may be different, butsometimes I find it is difficult to unravel their thinking and I will just have to try something else.So, it depends on the individual. Yes, the team approach for diabetes is crucial and we knowthat diabetes is a multisystem disorder and so definitely would benefit from a team that usesdifferent multisystem or specialty approaches in management and avoiding complications.Developed  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  3. 3.  Because of the high rate of disability, increased utilization of healthcare system, increased lostdays from work and so forth, it is really crucial that we work together as a team because no oneperson can do it all. We know from research from the DCCT and the KTDS that diabetes can bemanaged successfully with early aggressive and ongoing treatment. So, all the more reasonthat we need to work together as a team.In the successful management of type 2 diabetes we treat glycemia, the dyslipidemia andhypertension. We commonly call this the ABCs of diabetes: A1c, blood pressure, andcholesterol and we actually can add more, but the ABCs is the most important. We have tocontinuously be working proactively with the patient and just focus on getting the ABCs in orderto prevent the short-term and the long-term complications and improve our patient satisfactionwith the results.Primary healthcare providers do manage 80-90% of the diabetes care in the United States, butthey are unable to provide all the components of comprehensive care of diabetes that includetelephone; face-to-face visits; group managements of the ABCs; continuing self-managementeducation skill and behavioral intervention; reduction of risk factors; health promotion and eventhe periodic examinations to monitor for treatment and complications. The most important thingis the team approach, to combine the skills of the primary care providers with other healthcareproviders including patients and their family for a comprehensive program for the lifetimemanagement of diabetes. So, the team members can be many. We may have a physicianleader and nurse practitioner and PA or other specialties together and depending on which stateyou are in - I think in 16 states nurse practitioners are functioning independently as primary careproviders with their own practice and still work with teams of physicians and PA’s and otherproviders. Therefore the NP can also be a team leader.I think the most important point is that we work together and we understand what the skill mix isand what we bring to the practice. Tthe successful team approach includes having the group ofclinical staff work together, but the common goal is helping the patients to achieve improvedhealth and this could be centralized or decentralized depending on the resources, insurance,management constraints, and so forth. We need to have a system that is very coordinated andcontinuous in terms of patient care. We need to identify and involve all other team membersand their roles. One other strategy in successful teams is identifying the patient population andyou can use stratification of patient population according to their therapeutic needs. In ourclinic, we have diabetes registries and based on performance measures, we can pull up patientswho have high A1c levels, blood pressures, lipids not controlled, increased cardiovascular riskfactors, and any of the other risks or complications such as eye disease; blood disease,beginning microalbuminuria; risk factors of cigarette smoking or alcohol use; family history andso forth. It is important that we do identify the patients who are at a higher risk for complicationsDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  4. 4.  and comorbidities. When you are starting a team group practice or model in your facility, youwant to start by identifying the patients at a higher risk. Often it is important to keep in mind thatthere might be breaking points where there is higher risk than usual. In this case, they arenewly diagnosed with diabetes or they are just starting insulin therapy or their A1c levels areconsistently above 8%. There might be other limitations in terms of reimbursement, finances,insurance coverage or cognitive and psychological barriers.In the VA, we have a lot of mental health and posttraumatic stress that also complicates thetreatment regiment. Therefore we have to keep that in mind as we recruit these different groupsand work with them. So, we have to basically adjust the services to meet the patient’srequirement and that is really the whole critical team approach. Individual patients may requiredifferent types of team members to serve their individual needs. This focuses on the patient asbeing the central component of the team and team members are focused on meeting patientneeds. One issue will be selecting the coordinator of the patient’s care and that may be theprimary care provider or may be RN, CDE or your PA, it depends on your facility and the coreteam.Team mates of course would have to include the provider, team leader or coordinator andeither a medical assistant or nurse. So, again it depends on your facility, but that is the coreteam. The team meets and they communicate regularly about the care of the patient and wecall that huddles. So, when you get together and either you are talking about the patients thatare coming in or at the end of the day the patients have left and what follow up needs to bedone. The focus of the team then is very holistic, integrating their biomedical needs as well astheir psychological and sociological factors that we have to enable in order to have thattherapeutic alliance with the patients and help to empower the self-management.Again the inclusion of the health promotion models, the motivational interviewing, changetheory, behavior action plans and the healthy interaction conversation will enhance ourmanagement and skill building in our patients. The team members also have to have someonewho assumes the responsibility as the health coach and there can be more than one teammember, but the health coach skills include setting the agenda (when the patient comes in),discussing diabetes care, talking about medication reconciliation, closing the loop and followingup and helping to work on behavior action plans. The health coach basically serves to supportand encourage the patient. They spend time listening to their concerns and what is going onwith their life, communicating to other team members and making sure that everybodyunderstands what is going on, with the patient’s permission. Therefore this care would belocally developed and with consensus based guidelines. I believe that Dr. Zonszein talkedabout that already, about the ADA guidelines and so forth. Teams may also integrate otherconsultants and experts in more of a multidisciplinary team. Our team has a clinical pharmacistand we just love having our clinical pharmacist because it is so wonderful to have someone whois very expert in the medication management to consult with. Having a dietitian, diabetesDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  5. 5.  educators, endocrinologist, diabetologist, nephrologist, neurologist, and any other specialties isso important in the team and it is nice that you have them as part of your core team, but it is notalways possible. Often times you do have to build relationships with the other providers in thecommunity and make your referrals and make sure that you have all of the elements you needto meet the patient’s needs.The CBC published a guide for pharmacy, podiatry, optometry, and dental professionals also tohelp meet some of the specialty healthcare needs of people with diabetes. An example of themultidisciplinary team is the CBC diagram, which is an excellent diagram of what the team couldlook like. Also, it is important in the team approach to have group visits and you can havepatients come in for one to two hours visits; groups of patients may be just foot care and havethe provider go over some of their management, the health coach may go over some of theirbehavioral action plans and so forth. Working together in groups is an ideal way becausepatients really benefit from peer support and peer learning. So, it is an excellent methodologyalso in team approach.     Developed  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.