Standards of Medical Care in Diabetes 2018

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPThe American Diabetes Association (ADA) publishes guidelines each January to educate professionals about the best clinical practice for people with diabetes. Beginning in 2018 the ADA will publish updates online as they become available if new evidence or regulatory changes require immediate incorporation. The new recommendations include the areas of cardiovascular health, health technology, screening , and patient centered care. These standards are meant to provide general treatment goals for people with diabetes. They are not meant to replace clinical judgment. I am going to briefly review some of the changes this year.  A more detailed explanation of the standards can be found here.  Please remember, that these are in no way meant to replace the individual care that you are participating in with your health care team.

Section 1: Improving Care and Promoting Health in Populations

Care for people with diabetes includes assessing for financial resources, access to care, stability of housing situation, ability to access healthy food, and medication use.  Additional support for diabetes self-management can come from community health workers, navigators (who help “navigate” health insurance and claims), and lay health coaches who help with self-management.

Section 2: Classification and Diagnosis of Diabetes

Certain medical diagnoses can make A1c test results less accurate. People with conditions that affect red blood cells, such as sickle cell anemia, may get an incorrect result. It is important to use other methods to test for diagnosis and control of diabetes such as fasting and postprandial (after meal) glucose levels.

Section 3: Comprehensive Medical Evaluation and Assessment of Comorbidities

Pancreatitis is now listed as a comorbid condition (another condition a person can have along with diabetes).

Serum testosterone should be checked in men with symptoms of hypogonadism.

Section 4: Lifestyle Management and Section 6: Glycemic Targets

Both sections address the ADA recommendations for using technology to help with diabetes management.  This could include teleconference, text messages, or email. The use of continuous glucose monitoring (CGM) for people with Type 1 Diabetes should start at age 18.

Section 8: Pharmacologic Approaches to Glycemic Treatment

Recent study data has shown that all patients newly diagnosed with diabetes should be following strict lifestyle changes and start metformin. People with heart disease should consider additional medication(s) that may reduce cardiovascular events/mortality.

Section 9: Cardiovascular Disease and Risk Management

People with hypertension (high blood pressure) and diabetes should monitor their home readings to help to identify white coat hypertension and to improve medication management and following directions for taking medications. The ADA defines hypertension as blood pressure of 140 or greater /90 or greater.

Lipid management recommendations were changed to group risk in two broad categories: with heart disease and without.

Section 11: Older Adults

It is very important to individualize medical therapy in older adults to achieve the best results without any adverse reactions, such as hypoglycemia. A1c target should be adjusted for age and other medical conditio

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Diabetes Care Redesign: Spotlight on Collaboration in Patient Care

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Partners HealthCare is currently undergoing a process of care redesign in several hospital areas and conditions to improve the value of care provided to our patients by increasing the quality of care while decreasing cost. Partners established several goals for Diabetes Care Redesign, including increasing the appropriate use of insulin. Here at Mass General, we used this as an opportunity to develop a population management strategy to start eligible patients on insulin earlier, incorporate behavioral and lifestyle approaches into the diabetes care plan at this important touch point in diabetes care, and minimize the side effects of insulin therapy (hypoglycemia and weight gain). To do this, we convened a multi-disciplinary group of stakeholders, including primary care doctors, endocrinologists, nurse practitioners, nurses, dietitians, psychologists, pharmacists, and others to develop best practices for insulin initiation and titration. Over the past year, the MGH Diabetes Care Redesign Team has been working to implement its innovative new insulin initiation process within several primary care practices. 

Three sites are currently piloting this program: Internal Medicine Associates (IMA), Women’s Health Associates, and MGH Back Bay. In the pilot, a nurse from each practice’s diabetes management team is designated as the Diabetes Champion. Using TopCare Diabetes, an online population management tool, the Champion identifies which patients in the practice are eligible for insulin initiation and titration and reviews the care plan with the primary care provider. The primary care provider, in turn, begins a discussion with the patient about starting insulin. Eligible patients are screened for potential medical or behavioral barriers to success (e.g. depression, lack of motivation, fear of needles). They are then enrolled in a coordinated care process that promotes rapid cycle change, in which the Diabetes Champion uses frequent phone- or visit-based contact to help the patient start and adjust the insulin dose instead of following the usual every 3 month visit pattern.

The entire process lasts several months but reduces the overall time to develop a successful treatment plan. It includes follow up visits with both providers and dietitians, and phone calls by the Diabetes Champion to provide between-visit support. The Diabetes Champion serves as the care manager overseeing every step of the process from the preparation phase, to the insulin start phase, to follow-up after successful insulin initiation. Many of the elements incorporated into this plan were adopted from those already being done informally at many practices. The new process creates a formal standard for providers to learn from best practices and incorporates new elements from other disciplines, specifically nutrition/lifestyle and behavior change, into routine diabetes care. It also meets many chronic disease management criteria required for Patient-Centered Medical Home certification.

At its heart, the Diabetes Care Redesign is all about collaboration; participants from various areas came together to share their knowledge and learn from others’ experience with caring for patients with diabetes.  The project has been led collaboratively by Deborah Wexler, MD of the MGH Diabetes Center and Stephanie Eisenstat, MD (Women’s Health Associates) blending specialist and primary care expertise; Elizabeth Geagan, MHA (Endocrine Division); and Gianna Wilkins, BS (Process Improvement). In particular, the nutrition curriculum was developed by an international expert in diabetes nutrition, Linda Delahanty, MS, RD, LDN working with Lillian Sonnenberg (DSc, RD) Assistant Director, Community Nutrition, and Melanie Pearsall (RD, CDE) of MGH Revere.  Other key contributors to the project include Barbara Chase (APRN, BC, ANP) of MGH Chelsea and Marcy Bergeron (RN, MS, ANP) of the Bulfinch Medical Group, who have spearheaded diabetes population management at their practices for many years; Anne Thorndike, MD of the MGH Division of General Internal Medicine, an expert in behavior change in obesity; and Mira Kautzky MD, a primary care physician in the IMA. We welcome patient participation and feedback in the process; please contact Deborah Wexler, MD if you are interested in learning more.

The Care Redesign process represents a paradigm shift – a fundamental change in how we approach diabetes care. Team-based care requires changes in practice organization, and developing workflow to fit within the Patient-Centered Medical Home model presents its own challenges. But it has been a gratifying experience working with so many people from a range of disciplines, learning from and incorporating their experience and expertise in this effort. It’s our hope that the work we have done with Diabetes Care Redesign will serve as a model for other departments undergoing their own care redesign efforts.