The Multidisciplinary Approach to Managing People With Diabetes, Guidelines for Care
In this video roundtable discussion, Carol Wysham, MD, interviews Eugene E. Wright, Jr., MD, and Hope Warshaw, MMSc, RD, CDCES, BC-ADM, about the multidisciplinary approach to managing people with diabetes and guidelines for care, including the value of utilizing the services of a certified diabetes care and education specialist, the pharmacologic approaches to managing patients with diabetes, and the importance of lifestyle changes and diabetes self-care and management, and more.
Additional Resource:
- Hope Warshaw. Accessed October 25, 2023. https://www.hopewarshaw.com/
For more diabetes content, visit the disease state hub.
TRANSCRIPTION:
Dr Carol Wysham:
Welcome to Consultant360. Today's episode will be the Multidisciplinary Approach to Managing Patients with Diabetes and Guidelines for Care. I'm Dr Carol Wysham. I am joined by my two esteemed colleagues, Dr Eugene Wright and Ms Hope Warshaw. Would you two please introduce yourself and define your role in managing patients with diabetes? Dr Wright?
Dr Eugene Wright:
Hi. I'm Gene Wright. I'm currently the Medical Director for Performance Improvement at the South Piedmont Area Health Education Center. As a primary care clinician, we see patients not with just diabetes but many of the comorbid conditions, so we have the luxury of becoming multi-specialists in that regard.
Dr Carol Wysham:
Thank you, and Hope?
Hope Warshaw:
Hi. Delighted to be with you. So by background, I am a registered dietician, as well as a Certified Diabetes Care and Education Specialist. I've spent my entire career, 40-plus years in the diabetes care and education space. Today I have a private practice, and I do a good bit of diabetes technology device training, as well as a lot of consumer and professional writing for publications.
Dr Carol Wysham:
Thank you. I am an endocrinologist. I work in a multi-specialty clinic. I'm very happy to say for my 40-plus years of practice, I have always had what previously was known as diabetes educators embedded in my practice, which is something that I felt was very important for my role. So Hope, I'd like to start with you and help clarify the role of a CDCES, previously Diabetes Educator. Can you explain perhaps why the change in the title so that helps the audience understand that?
Hope Warshaw:
Sure. So first let me mention that there is an association, the Association of Diabetes Care and Education Specialists. There is a certification that people can take an exam for, and that is the CDCES, or you can become a Certified Diabetes Care and Education Specialist. So it was about 2020, after about probably 40 years with the Diabetes Educator title that there was a name change. That was very intentional to embrace the term care along with education because we as Diabetes Care and Education Specialists don't just do this didactic education with people with diabetes. We are very much integral to their care.
I'm delighted to hear, Carol, that you are such a proponent of having a CDCES aligned with you in your endocrinology practice. I am certainly in favor of more endocrinologists and more PCPs who as we know are doing so much care for people with diabetes today. We know PCPs are seeing the majority of people with diabetes. I think a CDCES in your practice can help both with care and education, two things people very much need. I assume we'll get into talking about devices eventually.
Dr Carol Wysham:
Yes. Yes, of course. So Gene, tell me about your experience of working with CDCES on site, in practice, referrals. Tell me about your experience.
Dr Eugene Wright:
Well, Carol, as a primary care clinician, I've worked in many environments. However, I can undeniably say that having a CDCES onsite is the best for many reasons. You and your patient can have ready access many times at the same visit to discuss a dual approach to diabetes management. Lifestyle and pharmacotherapy are two of the pillars of diabetes management. Lifestyle management is foundational to diabetes as well as other diseases. So, we as clinicians are trained in pharmacotherapy while our colleagues in Diabetes Care and Education Specialists are trained in lifestyle and education to include diet and activity. So having access to a CDCES via referral is often not taken advantage of by my colleagues in primary care. However, recent trends in remote and televisits have made these much more accessible.
Dr Carol Wysham:
My experience is that our CDCES will go into primary care. So they each have a rotation with the various primary care so that they have the experience and the access for their patients. So, thank you. Hope, tell me how your role in managing people with diabetes has changed over the last 40 years. That's an amazing career, and I know you've seen a lot of changes, so can you explain how that has happened?
Hope Warshaw:
Sure. First, I just wanted to say I am a dietician by background and CDCESs have multiple of disciplines Today you're seeing more nurse practitioners who are CDCESs. You're seeing many more PharmDs who also specialize in diabetes. Some of us do have prescriptive authority, which puts us in a very different realm. As a registered dietician steeped in diabetes, I feel extremely competent in say, following a signed-off algorithm for moving someone along with a medication.
I mean, by background, dieticians certainly are very focused on meeting people where they are, not doing what I think we used to do, which is handing someone a diet with the expectation that they're going to run home and follow it. It just doesn't work that way, so I think where things have evolved particularly in lifestyle management and nutrition management is that meeting someone where they are. Doing a nutrition assessment, figuring out and asking those food insecurity questions, which I think today are becoming so relevant. Before you even start talking about what you should be eating, what you want to eat is, "Do you have the food to eat?" I mean, it is very expansive in terms of, I think the expertise that particularly the dietician as a CDCES brings to the table.
Dr Carol Wysham:
I think that's absolutely true, and none of us are very well educated on that nor do we have the time and the insight that you have. One of the other things that I think is really important for your role is the facilitation of communication. Can you explain how you do that in terms of putting together the information from the PCP and your information and perhaps a cardiologist or an endocrinologist?
Hope Warshaw:
So by putting together information, do you mean translating to the person with diabetes?
Dr Carol Wysham:
I was looking more at facilitating communication between members of the care team.
Hope Warshaw:
I mean, I think one has to be familiar with how those care team members communicate with each other. Is it electronically or is it within an EMR if you're in the same healthcare system? I think how we work with individual providers depends on the building of a relationship over time.
Dr Carol Wysham:
Yeah, I think that's key. That's certainly true. Turning to you, Gene, could you just outline your approaches to how you help to reduce risk of complications of diabetes in your patients?
Dr Eugene Wright:
Sure, but before I do that, I want to pick up on something that Hope said that it just sparked in my mind about the communication. One of the best lessons I learned about assessing a patient's risk for diabetes is from my dietician. She said one simple question you can ask the patient is, "Where do you shop for food?" Once you know that you have some idea of the environment, the lived experience the patient may have. So, I've found that my approach to diabetes and managing the risk for complications has been reshaped, if you will, over the years, so that my approach now is to not just think of diabetes as dysglycemia alone.
I think dysglycemia is a marker, but there's a lot more than that that's associated with that diabetes. Therefore, I've had to rethink this and when I see diabetes, know to look for the other associated or interconnected conditions such as dyslipidemia, cardiovascular disease, CKD, NAFLD, non-alcoholic fatty liver disease or metabolic-associated fatty liver disease. Now we know that by identifying and treating these conditions early and aggressively, we can get long-term risk reduction and benefits for our patients.
Dr Carol Wysham:
Do you want to outline your pharmacologic approach to managing patients with diabetes and perhaps your approach to separating between glucose, blood pressure, lipids, et cetera?
Dr Eugene Wright:
Yeah. That's great because we have a number of classes, at least 11 classes of medication for treating diabetes. However, the guidelines have evolved now to inform us to identify and treat comorbid conditions and risks early as a goal of therapy. Therefore, when we assess these risks and conditions, that will really direct our first and second-line therapy. Some of the glycemic approaches that we use now, glycemic reduction approaches, look if the patient has comorbid chronic kidney disease, weight problems, if they have blood pressure problems, or if they have lipid problems. We need to think of these not as individual conditions, but as a constellation of conditions that need to be identified and treated aggressively and early.
Dr Carol Wysham:
Great. Thank you. Hope, how can a CDCES help the patient, as well as the PCP, meet these goals for improving glycemia, blood pressure, and lipids?
Hope Warshaw:
I just wanted to comment on that question about what Gene was talking about. I mean, he was underscoring early, early, early. I think that is a fault of many of ours is that we don't react early. I mean, I do think the PCP, family practice, and internists, are on the front lines, but they're faced with so many problems that that individual may have. There's been a lot of conversation about how we even talk about obesity. But that is so critical to being addressed early on. I think we all realize there is a lot of work being done in diabetes prevention and Type 2 diabetes prevention. I think we need to clarify today. But the rate of people being referred to programs that are accredited by CDC, that are covered by Medicare is poor, poor, poor.
I could say the same for some of the services that are covered for dieticians. So, there is coverage by Medicare and other private insurers for what's known as medical nutrition therapy, covered for diabetes as well as end-stage renal disease. The utilization is horribly poor for diabetes education programs. There's diabetes self-management, education, and support, also a Medicare benefit, and poorly utilized. So, I think we are not good and have a lot of work to do in the early identification of issues. I mean, we know that jumping on those signs of dysglycemia is critical to preventing the progression of disease and preventing complications.
Dr Carol Wysham:
Yes. As I see it, oftentimes you're able to identify barriers that escape us in the clinic appointments and that can really help patients meet their goals. I really do appreciate the insights that you-
Hope Warshaw:
Yeah. I think that may just be reflected by we have a little more time to chat.
Dr Carol Wysham:
Well, but you're also focused on that. You're focused on the individual holistically. I think that really makes a big difference. Some of us have been trained by our education staff, if I can just shorten that, to help us understand how to ask those questions, but many of us just really don't have the insight that you have, particularly after 40 years.
So Gene, how about as a primary care provider, could you give me your definition of an optimal team to facilitate the care of patients with diabetes in primary care?
Dr Eugene Wright:
That's a great question, Carol. I've thought about this, and I characterized what I would call my dream team. It would be as follows, and I have to divide this, I have a frontline dream team, and I have a support dream team. So on the frontline with me as a primary care clinician, I would absolutely support a Certified Diabetes Care and Educational Specialist for all the reasons that Hope and you have identified. I think also a clinical pharmacist can be very valuable when it comes to reconciling medications and understanding those interactions that may elude us, what the patient is taking that's not prescribed, and the importance of that in diabetes management.
A behavioralist. Many of the patients that we see with diabetes have diabetes distress. Not all of them move to diabetes with depression, but being able to sort that out and having an outlet for them to discuss the challenges that they see, as well as an exercise physiologist. I've learned over the years that the routine exercises that I would give a patient without diabetes are not always realistic for a patient with diabetes. They have lots of things going on, so having someone who specializes in exercise physiology and tailoring a program for the patient.
Now this is my dream team, mind you. Then as a support to that dream team, certainly an endocrinologist, a cardiologist, a nephrologist, and probably now knowing the association between metabolic-associated fatty liver disease, a hepatologist to understand who are those patients that need to be screened with what tool and when to treat and when to refer. So this team would work together collaboratively to help me and my patients see that they are achieving the best possible care and have access to speedy referrals when needed.
Dr Carol Wysham:
Yeah. It's helpful to inform the patients of the importance of this team because otherwise, I think they have this concept that number one, they can do better on their own. Number two is that the care provider, the physician, or the nurse practitioner is the person who is going to be providing all of their care. So yeah, making sure they understand that it does take a team. Hope, would you mind reflecting on the changing landscape in glucose monitoring?
Hope Warshaw:
Sure, so I'll tell you that I came into diabetes care basically when that transition between urine glucose monitoring and blood glucose monitoring came into being. So, to say I've seen a lot of change is an understatement. One of the things I'll say about blood glucose monitoring is that I think that the availability of continuous glucose monitoring today to some people that we've thrown the baby out with the bath water. I don't think that that is a wise thing to do. I'm focusing my comments, particularly on people with Type 2 diabetes who may not be able to have a CGM.
The blood glucose monitors today, they're very small. The test is very quick. They sync with an app. Some of them give people actionable insights, so they are very valuable. I think a critical piece is that we need to teach people, and this is something that a CDCES can do, teach people to check smart, when to check that will give you the most valuable information, and then make sure that you review that data with people and that they see how valuable having that data is to your management. I think that reinforces.
The availability of CGM is incredible. It has given so much data for us clinicians, but I think a challenge really in the primary care world is, "Oh my God. What do I do with all this data?" I think again, that's where CDCES can be extremely helpful in helping people select a device to determine what they can have covered, to train them on using the device, and then really to utilize the data.
I mean, one thing I will add, generally speaking, is sometimes I don't think there's an awareness of the coverage of reimbursement for a number of the services that we're talking about. Medical nutrition therapy, diabetes self-management education and support, training people on devices, and reviewing data. There are a number of different ways to organize a practice to benefit from some of the coverage. Not that it's easy by any stretch and not that it's a lot of coverage, but it can be done.
Dr Carol Wysham:
I think you bring up a really good point, and that could be the subject of an entire episode just discussing the different options for glucose testing, whether it be fingerstick glucose testing or continuous glucose monitoring, and the use and the referrals that can be made and the coverage that can, now when is appropriate and when can you get coverage under healthcare for these services. So yeah, that is very helpful. I think the continuous glucose monitoring has been absolutely monumental for my practice with patients that have Type 1 diabetes as well as those patients with Type 2 diabetes on insulin. Well, listen. I would like to start with Gene to just say or ask him how he uses the data from CGM in his practice.
Dr Eugene Wright:
Carol, I thought about this. There's I think two statements that I can make I think that really summarizes this. I use CGM as a tool to facilitate an intervention, and that intervention is not always on my part. Many times it's on the part of the patient. The second thing that I would say about CGM and the ambulatory glucose profile is that it has the ability to take a large data stream, a large amount of data collected over 10 to 14 days and convert that, transform that, if you will, into actionable information. The way that it does that is it organizes it, analyzes it, summarizes it, and it presents it in a graphic form that even my colleagues and my patients who may have trouble with numbers can see and recognize patterns and trends and make sound recommendations on behavior and medications based on that.
Dr Carol Wysham:
I think that's really helpful. Hope, tell me about your use of CGM in your practice. I know that you do a lot of education and have a lot of experience with it. How do you use that to facilitate your conversations with your patients?
Hope Warshaw:
I think it is a great way to engage people and ask them questions. What are you observing? I mean, we have all the data in front of us, so we can let go of those questions about, "What about this blood sugar and why did this happen and where are your numbers? What are your numbers doing? When did you eat?" I mean, it's right there in front of you. So, I think it's so important with this disease, diabetes, to engage someone in their care. It is probably the most self-managed disease that we see. The more that we enable that person to be aware of the whys and wherefores of the numbers and the actions that they can take in their daily management to achieve the goals or time and range that we're talking about, I think we're going to be better off. So making a person the manager of their diabetes and less dependent on coming to one of us once in three months or twice a year.
Dr Carol Wysham:
Yeah. That's very good. Well, I want to thank you both for just an incredible conversation today. Very insightful. I would like to give an opportunity starting with Hope to perhaps summarize or give a take-home message that you'd like someone to go away with today.
Hope Warshaw:
Well, since I'm the champion of the Certified Diabetes Care and Education Specialist, I would hope that one of the key messages that we're leaving primary care providers and endocrinologists with is to find one of us and partner with one of us. See if you can offload some of the things that you're doing and together improve outcomes.
Dr Carol Wysham:
Great. Thank you, and Gene?
Dr Eugene Wright:
Well, I can only add to what Hope has said, that we have a number of resources that are available to help us care for and manage our patients with diabetes. We need to become aware of them and utilize them fully.
Dr Carol Wysham:
Great. Well, thank you, Hope and Gene. I want to thank the audience for tuning into this Consultant360 video.