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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 more
than that. It is providing a healthy diet, trying to motivate the patients to exercise. By the way
when I say a healthy diet, I do not mean only caloric reductionI mean changing to less calories
and making it healthier. So, less fat food, less simple carbohydrates, and those are easy things
to do. Patients need to understand why we do that. I find in the Diabetes Self-Management
Educational Classes that patients have a tremendous amount of interest in learning on howto
eat well. Even if we do this day in and day out, patients do not believe that when they buy a
gallon of orange juice or when they put fruits in the blender they are consuming an enormous
amount of sugar.
We have to explain that even in the orange juice,even when written on the label “no sugar
added”, the amount of sugar (simple carbohydrates), is not different from what we have in a
bottle of Coca-Cola or Pepsi Cola. So, they have to learn this. They sometimes have questions
that 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 dietary
recommendations, but also in how to overcome some of the barriers in changing the habits that
these patients have for so many years. In our center, when we educate a patient in better
eating we want to make an impact on the entire family, not only in the patient. It is similar as in
smoking cessation, if the partner of the person that wants to stop smoking also smokes, it is
very 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 dietary
regimen is important not only for the patient but for the entire family; the person who goes
shopping, 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 healthier
diet not only in people who have diabetes, but also we want it in their children who are at very
high risk to develop diabetes because they do have a parent with diabetes. So, family changes
are important.The person does not have to become a nutritionist, but needs to acquire basic
knowledge about what type of foods to eat and how to prepare the food. We have been using
the plate model that was recommended recently by the U.S. Department of Agriculture. Then
we go to the other educators in the team, which are the registered nurses; they tend to be better
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.

2.
than physicians in providing education and finding out some of the barriers we, physicians, often
overlook. Nurses are very good at explaining to the patient and finding what the barriers are
and how to overcome those barriers. When the patient sees that there is a team of anutritionist
and 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, the
dosage, the drug interaction.Asocial worker is also particularly important in the area where I
work where patients have major social issues, they help arranging their finances for getting the
medications, better housing, etc. Other specialist physicians are also part of the team. Not
everybody who has diabetes needs to see a podiatrist, but Podiatry care and education for
prevention 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 after
developing their disease because that is when complications may start to develop. We want
patients who have type 2 diabetes to start seeing an ophthalmologist at least once a year since
the diagnosis of the disease,to prevent and avoid retinopathy.
So, the ophthalmologist, the podiatrist, the pharmacist, the social worker, the nurse, the
nutritionist are all part of the team and unfortunatelythose patients who already have organ
disease such as heart disease or kidney disease may need to see also a cardiologist or a
nephrologist. Again when we treat this complex disease called diabetes we need more of a
team approach to better help the patient. Having said that the person who is at the center of the
team is always the patient and what we try to do is to empower the patient and have the patient
take the initiative to continue to take care of themselves again through education and a team
approach.
Lenora Lorenzo, DNP, APRN, FNP/ADM: Another challenge in terms of medication is the
media. It has now published every known side effect to every medicine and patients get very
confused and alarmed. Therefore when they do come in and we start them on a new medication
that they heard about from TV, they may have preconceived ideas and they may report the side
effects that nobody ever gets so it is a challenge to deal with that. I try to forewarn them and let
them know that there are common types of reactions that people may or may not have and that
there are some that are very unlikely to happen, but that the media, to protect themselves
legally, will give them information. So, I try to get them to realize that may be different, but
sometimes 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 know
that diabetes is a multisystem disorder and so definitely would benefit from a team that uses
different 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.
Because of the high rate of disability, increased utilization of healthcare system, increased lost
days from work and so forth, it is really crucial that we work together as a team because no one
person can do it all. We know from research from the DCCT and the KTDS that diabetes can be
managed successfully with early aggressive and ongoing treatment. So, all the more reason
that we need to work together as a team.
In the successful management of type 2 diabetes we treat glycemia, the dyslipidemia and
hypertension. We commonly call this the ABCs of diabetes: A1c, blood pressure, and
cholesterol and we actually can add more, but the ABCs is the most important. We have to
continuously be working proactively with the patient and just focus on getting the ABCs in order
to prevent the short-term and the long-term complications and improve our patient satisfaction
with the results.
Primary healthcare providers do manage 80-90% of the diabetes care in the United States, but
they are unable to provide all the components of comprehensive care of diabetes that include
telephone; face-to-face visits; group managements of the ABCs; continuing self-management
education skill and behavioral intervention; reduction of risk factors; health promotion and even
the periodic examinations to monitor for treatment and complications. The most important thing
is the team approach, to combine the skills of the primary care providers with other healthcare
providers including patients and their family for a comprehensive program for the lifetime
management of diabetes. So, the team members can be many. We may have a physician
leader and nurse practitioner and PA or other specialties together and depending on which state
you are in - I think in 16 states nurse practitioners are functioning independently as primary care
providers with their own practice and still work with teams of physicians and PA’s and other
providers. 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 is
and what we bring to the practice. Tthe successful team approach includes having the group of
clinical staff work together, but the common goal is helping the patients to achieve improved
health 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 and
continuous in terms of patient care. We need to identify and involve all other team members
and their roles. One other strategy in successful teams is identifying the patient population and
you can use stratification of patient population according to their therapeutic needs. In our
clinic, we have diabetes registries and based on performance measures, we can pull up patients
who have high A1c levels, blood pressures, lipids not controlled, increased cardiovascular risk
factors, 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 and
so forth. It is important that we do identify the patients who are at a higher risk for 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.

4.
and comorbidities. When you are starting a team group practice or model in your facility, you
want to start by identifying the patients at a higher risk. Often it is important to keep in mind that
there might be breaking points where there is higher risk than usual. In this case, they are
newly diagnosed with diabetes or they are just starting insulin therapy or their A1c levels are
consistently 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 the
treatment regiment. Therefore we have to keep that in mind as we recruit these different groups
and work with them. So, we have to basically adjust the services to meet the patient’s
requirement and that is really the whole critical team approach. Individual patients may require
different types of team members to serve their individual needs. This focuses on the patient as
being the central component of the team and team members are focused on meeting patient
needs. One issue will be selecting the coordinator of the patient’s care and that may be the
primary care provider or may be RN, CDE or your PA, it depends on your facility and the core
team.Team mates of course would have to include the provider, team leader or coordinator and
either a medical assistant or nurse. So, again it depends on your facility, but that is the core
team. The team meets and they communicate regularly about the care of the patient and we
call that huddles. So, when you get together and either you are talking about the patients that
are coming in or at the end of the day the patients have left and what follow up needs to be
done. The focus of the team then is very holistic, integrating their biomedical needs as well as
their psychological and sociological factors that we have to enable in order to have that
therapeutic alliance with the patients and help to empower the self-management.
Again the inclusion of the health promotion models, the motivational interviewing, change
theory, behavior action plans and the healthy interaction conversation will enhance our
management and skill building in our patients. The team members also have to have someone
who assumes the responsibility as the health coach and there can be more than one team
member, 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 following
up and helping to work on behavior action plans. The health coach basically serves to support
and encourage the patient. They spend time listening to their concerns and what is going on
with their life, communicating to other team members and making sure that everybody
understands what is going on, with the patient’s permission. Therefore this care would be
locally developed and with consensus based guidelines. I believe that Dr. Zonszein talked
about that already, about the ADA guidelines and so forth. Teams may also integrate other
consultants and experts in more of a multidisciplinary team. Our team has a clinical pharmacist
and we just love having our clinical pharmacist because it is so wonderful to have someone who
is very expert in the medication management to consult with. Having a dietitian, diabetes
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.

5.
educators, endocrinologist, diabetologist, nephrologist, neurologist, and any other specialties is
so important in the team and it is nice that you have them as part of your core team, but it is not
always possible. Often times you do have to build relationships with the other providers in the
community and make your referrals and make sure that you have all of the elements you need
to meet the patient’s needs.
The CBC published a guide for pharmacy, podiatry, optometry, and dental professionals also to
help meet some of the specialty healthcare needs of people with diabetes. An example of the
multidisciplinary team is the CBC diagram, which is an excellent diagram of what the team could
look like. Also, it is important in the team approach to have group visits and you can have
patients come in for one to two hours visits; groups of patients may be just foot care and have
the provider go over some of their management, the health coach may go over some of their
behavioral action plans and so forth. Working together in groups is an ideal way because
patients really benefit from peer support and peer learning. So, it is an excellent methodology
also 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.