Hello, everyone, and welcome to Diabetes Primary Online Learning Collaborative Webinar entitled Mastering Diabetes Care Essential Tips, Tools, and Strategies for Primary Care Providers. Today, our panelists will engage in a roundtable discussion, and we are glad you are here. I am so glad that we have had this time together. This is our last webinar, and we are so appreciative for everyone tuning in, and we hope to give you some really great information today to help you take care of diabetes patients and give them quality care in your practices. My name is Paige Johnson. I'm the moderator, and you've seen me for the other two webinars. I'm an RN, CDC, yes. I work at an outpatient clinic in a diabetes education center located in Winston-Salem, North Carolina, and I work for Atrium Wake Forest Baptist Health Advocate. Today's agenda is pretty simple. We're going to have some brief introductions, and then we're going to do a roundtable. What is actually more in our little circle, we call it the family feud. We're all one big family, primary care providers and endos in our institution. What we're going to be doing is we're going to start our discussion today off with a little fun, and we're going to play a short round of family feud and just use it as an icebreaker. We'll be using the Zoom Q&A, so if you have questions that you think of during the presentation, just drop them in the Zoom Q&A, and we'll get to them. We are really conscious of trying to allow 30 minutes at the end of this webinar for questions and answers because that is what our main goal is, to actually help you at the end of the day with any questions that you might have about this. Today, our panelists, this is a great group of women. I love these women. I work with all of them. They are so intelligent. They're so fun to work with. We've got Bobbi Harmon. She is an RD, CDCS. She serves as an ADA, Diabetes Education Program Coordinator at Atrium Health Wake Forest Premier. It's actually a private practice endo office. She's very passionate about integrating diabetes technology. She was my coordinator at one point in time, and she is just phenomenal. We have Carrie Key. She is a PA that is employed by Atrium Wake Forest. She has been practicing in the field of endocrinology soon after completing her PA degree, and she is the technology guru. I have such fun with Carrie and technology. We do a lot of forensic diabetes, I always say, when it comes to us. We have Dr. Jessica Coutts. She's a board-certified internal medicine and pediatrics. She does practices in primary care in both of the disciplines. She practices in a clinic called Care Plus. We're going to learn more about that clinic in the webinar. It's a multidisciplinary primary care team focused on individuals that are high utilizers for hospital services. Then we have Dr. Uso. He's a board-certified endo. Dr. Uso and I do a lot of research together. She is so intelligent, and she's just a great asset to our team. She's actually a staff physician at the Bill Hefner VA Medical Center there in Kernersville, North Carolina, which isn't far from our base hospital. She enjoys investigating new technologies, and her interest particularly is in the older adult patients with diabetes. Then we have Dr. Jessica Valente. She's an assistant professor of internal medicine at Wake Forest School of Medicine, and she completed a residency at the University of California, San Francisco. She serves as a medical director to Care Plus. This is the disclosures for all of the panelists, which you'll notice they have none. Then next, what we're going to do is we're going to let the games begin. What I wanted to do today is I'll be your host, Stephanie Harvey, and we're going to start the family feud out with our very first question, and it is what are the five critical times to refer to diabetes education? Oh, Dr. Valente, I see your hand. Thanks for picking me. All right, so the five critical times to refer to diabetes education. So at diagnosis, annually, if your patient is not at goal, if your patient has new complications that have arisen from their diabetes, or if they've had life changes that have come up, those would all be times to refer to diabetes education. Perfect. You got one score for the primary care team. All right, next question. What lab tests do you order if you suspect a patient has type 1 diabetes? Oh, Dr. Coutts. Thanks for choosing me, Paige. That would be the C-peptide and GAD antibodies. There you go, and you can order those in your primary care office, correct? Perfect, perfect. Next question, and our questions get a little harder as we go, so just letting you know, what is the automated insulin delivery system that allows the autocorrections to be turned off? Ah, Dr. Hutho. Yes, that's a great question. That's the Medtronic 780G. Yes, you know a lot of people don't know that, by the way. All right, next question, and like I said, they get a little harder. What AID, or automated insulin delivery system, gives extended meal boluses without having to switch from automated to manual mode? Carrie! That is our Tandem systems, so Tandem T-SLIM and Tandem MOBI. There we go. All right, so last question. We're going to end up this round with one more question. What are the insurance companies that pay for diabetes self-management education services? Bobby! That's a very important question. It is Medicare and Medicaid. Oh, you know, you'd be amazed a lot of people that do not know that. They only think it's covered under commercial insurance. So we are here to be informative to all. So now what we're going to do is we're actually going to move into our panel discussion, and we are going to start with Dr. Valente. Dr. Valente is going to start by kind of sharing with us where she works, because it's very unique. Always tell people that if Dr. Valente and her staff can take care of diabetes, patients with diabetes, and have a five-star facility there, anybody can do this. All right. Well, thank you, Paige. So I just wanted to share a little background about our clinic, because it is pretty unique. So I practice at Downtown Health Plaza. It is one of North Carolina's busiest primary care practices. We are really a safety net practice. So we serve primarily patients with Medicaid or those with limited access to health care. And within Downtown Health Plaza, I have the great privilege of practicing on the CarePlus team, which, as Paige alluded to, we are a high-intensity, multidisciplinary team that is mostly focused on patients who are frequently hospitalized or kind of listed as our high utilizers of the health care system. And our patients have a whole host of comorbidities, lots of complicated psychosocial backgrounds. Majority of our patients have diabetes. In fact, they have not only diabetes, but lots of complications of their diabetes. We have a significant number of patients with cognitive impairment, so about 70% of our patient population. And a large number of our patients have limited literacy. And so when Paige approached me and others approached us about incorporating continuous glucose monitors technologies into the primary care setting, I was a little weary and probably underestimated our patient population. But we have been probably one of the biggest users and implementers of the CGMs in our primary care practice. And we've seen huge payoffs. So we've seen our patients have reductions in their A1C. We've seen improved glycemic control. But I think importantly, our patients are finally grasping and understanding and really autonomy in how they manage their diabetes. A big learning point for us was thinking about some of the disparities of diabetes technologies and how we could be equitable in offering these technologies to our patient populations. And so having the opportunity to think about technology with our Care Plus patient population has really been an important motivator to the rest of our colleagues in primary care about how to incorporate these technologies in our settings. So I want to share a patient story, which was this patient's very near and dear to my heart. But this was a gentleman. He's 60 years old. He had long-standing type 1 diabetes. He had a history of very severe complications of his diabetes. He was on a basal bolus regimen for a long time. He was pretty married to his Treceba 6 units and Novalog 3 units before meals. He had unfortunately developed significant peripheral arterial disease, bilateral leg amputations with chronic osteomyelitis. He had NSTEMI, chronic kidney disease. Importantly, he also suffered from not only low health literacy, but low overall literacy. And I just remember being very humbled one time I was actually sitting down with him in a visit and going through his after-visit summary thinking I was doing a great job of not only verbally kind of educating him on the medication management, but trying to visually show him the after-visit summary. And he very bravely looked me in the eye and said, Dr. V, I cannot read. I never learned how to read. So that was always a big learning point for me. But this patient not only had those complicated medical background and psychosocial background, but he also had a daughter who had type 1 diabetes and in her 30s had actually died of hypoglycemia. And so he was very, very appropriately fearful of hypoglycemia and had actually sacrificed his A1C and really did everything possible to avoid hypoglycemia at the risk of all of the diabetes complications he had developed. So his A1Cs for many years had always been 10% to 12%. And there was actually one follow-up visit where we ended up seeing him and at routine surveillance discovered that his A1C had dropped to 7.1%, which we celebrated and we were so excited for, but had a lot of caution and kind of thinking about why his A1C had dropped so much given his low BMI from his amputations and his other complicated comorbidities. And you can see he was actually doing a really good job of checking his blood sugars. He was checking four times a day and recording those, but had some concern for maybe more underlying hypoglycemia than what we were capturing on his home blood sugar monitoring. And so with the help of our clinic certified diabetes education specialists and a lot of education with the patient around how to use a continuous glucose monitor, we were actually able to introduce this technology to him and in fact found that his GMI was 7.3%, but we also saw that he was having 10% hypoglycemic episodes, and these were frequently happening in the early morning hours. He was asymptomatic, and it was definitely happening at a time when he was not checking his finger stick blood sugars at home. And so kind of empowered by this data and hearing the frequency of the alarms going off and visually being able to see the number of times his blood sugar was dropping, he was actually willing to work with us on adjusting the insulin regimen. So we were able to reduce his Truceba from six units to three units and continue the same dose of his mealtime insulin. We had him follow up about a month later, and his GMI remained at 7.8% with those adjustments, but now rather than having the 10% hypoglycemia, he had improved to 1% hypoglycemia, which was a huge win for him. And, you know, he actually was able in that time to see the data. We showed him the graph. that showed he still had a significant amount of hyperglycemia that was actually happening post-prandoly. And with that, he felt more empowered and willing to allow us to increase his mealtime insulin to the four units before meals. And so this was actually a really big win for us to be able to showcase the data, allow him to have the auditory reminders and the safety measures with the CGM, but also being able to finally make some movements in his insulin regimen. Unfortunately, a few months later, he actually received a diagnosis of metastatic lung cancer. And this was actually quite heartbreaking to the patient and his family. But recognizing that his overall goal throughout the entirety of my time knowing him had been to avoid hypoglycemia. We actually were able to liberalize his A1c goal to less than 10%. We had a long discussion about his frailty and his multiple comorbidities and his functional decline in status. And again, a conversation about what are his priorities right now. And he was very adamant that no matter what was happening with his cancer diagnosis and understanding his end of life, his biggest fear remained dying of hypoglycemia. And so he actually continued to utilize his continuous glucose monitor throughout the entire time he was diagnosed with this cancer with really that kind of ability to prevent hypoglycemia. And so this was a very pertinent patient case to me, because not only did the patient have therapeutic inertia, but I, as his primary care physician, had developed therapeutic inertia. We were so staunchly attached to preventing hypoglycemia in this patient, recognizing that was always been his goal that, you know, I kind of allowed his A1c to hang out in that 10% to 12%. But with the use of the CGM technologies, we were able to actually make adjustments to his insulin regimen, get him down to goal and respect his wishes of avoiding hypoglycemia. And that was, you know, a theme that continued all the way to his end of life, even though he died two months later, he died, you know, kind of with the peace of mind that the CGM gave him. You know, one of the things that we all kind of noticed as we started this care model of incorporating CGM at the Downtown Health Plaza in Care Plus with Dr. Valente and Dr. Coutts, you know, when I approached them about, you know, do you, you know, what level of involvement do you want? You know, I kind of had put a care model together for them about how involved they wanted to do and be with CGM technology. Do you just want to dip your toes in the water or do you want to do the deep dive? And I was so excited that Dr. Valente said, well, let's just do the deep dive. And she openly said, you know, I have a therapeutic inertia with hypoglycemia and I think this is going to help me and the patient. So let's go for it. And then, then Dr. Coutts joined us, and we've just been on the move ever since. She is going to share about a patient that's very near and dear to my heart and always keeps me on my toes. And I'll hand it over to Dr. Coutts. Thank you, Paige. So there'll be some similar themes as I do share a patient population with Dr. Valente. And I wanted to take this opportunity to just highlight some of the challenges that I feel like we face in treating diabetes in the primary care setting. And with our specific patient population, many of our patients come facing a multitude of these all at one time. But I think they still highlight the ones that come up in routine primary care. So I want to discuss these and then share a case, one of my most challenging cases of managing diabetes in my primary care clinic. And then some of the strategies we use to combat these challenges to work towards the A1C goal for this patient. So as I was coming up with the list of challenges in treating diabetes, I was a little disheartened in how easy it was to come up with a pretty long list. But once I got to the slide of strategies to combat these, I was surprised by how easy it also was to make that list. And I think with a team, as we'll discuss today, and many of the technologies we now have, we are much more equipped in primary care to combat these challenges we face. So many of these probably look familiar to a lot of you, but the challenges I have encountered most commonly in treating diabetes in primary care is first access to medications and the new technologies, many times being dictated by insurance coverage. But even once patients are able to access these medications and technologies, tolerance of them can be a challenge as well. And that goes back to our older medications like metformin or our newer medications, including the SGLT2 inhibitors or the GLP1 agonists. Now, if everything lines up and they have access to the medicines and they're tolerating them, adherence is our next challenge, right? And so I have seen this especially prevalent in patients on more complicated insulin regimens, multi injections per day, especially when we get to carb counting, a sliding scale, sometimes just medication treatment burden come to be at play. As Dr. Valente mentioned, our patient population specifically has a high rate of cognitive impairment with our average MOCA score being about 18 out of 30 in our patient population. And that often correlates with low health literacy as well. As Dr. Valente was discussing, fear of hypoglycemia is very prevalent, especially in our patient population. And we'll come up in the case that I discussed, but along with the fear of hypoglycemia, I've often seen incorrect treatment when it does occur. And this only makes our management of diabetes more challenging rather than following the correct kind of 1515 rule for treatment of hypoglycemia. I see my patients eat a whole bag of M&Ms in fear and that only creates a whole new issue. Next is just limited ability, feeling like there's a limited ability to impact diet. Many of our patients face food insecurity or a lot of what seems like lack of control over what they are eating day to day. And that can feel somewhat overwhelming when we're trying to take an approach beyond just pharmacotherapy. In primary care, our clinics are extremely busy and availability for patients to come back for that short interval follow-up to titrate medications, to review their response to a change in therapy can just logistically be a challenge or unrealistic. And the last challenge I've seen frequently is just the inability to gauge their current control. And I think this is where a lot of the technologies have helped me. You know, we have our A1C that we get every three months, but when a patient comes back in that interim, if we don't have home blood sugar data or CGM tracing, knowing next steps to take can be very challenging. So I want to highlight the case of Ms. S.B., who is a 68-year-old female who has poorly controlled type 2 diabetes that has been complicated by hypoglycemia with unawareness, to the point that she one day showed up to the clinic driving with a blood sugar in the 40s, completely unknowingly. She also has complications of her diabetes, including neuropathy and CKD stage 3. She has obsessive compulsive disorder and cognitive impairment with a mocha of 13 out of 30 when I met her, as well as hypertension. So when I met her in 2021, her A1c was 15% and she was on Ozempic 1mg weekly, Traceeba 20 units at night, Actos 30mg daily and Metformin 1000, which was renally dosed. And she had previously been on short-acting insulin, but given the concerns with her hypoglycemia and increasing frequency of such that had been discontinued. So when I met her, I felt a little bit strapped. She obviously had very poorly controlled diabetes, but it was hard to know where we could make moves in her regimen. Her medication options were limited by her CKD. There was a lot of fear surrounding this prior hypoglycemia and a lot of treatment inertia, as Dr. Valente mentioned, to make significant changes with the risk of that reoccurring. She also was living independently and with her cognitive impairment, there was just limitations into what she could actually execute in terms of a treatment plan and with limited insight into her disease or what this could mean for her long-term. So over the last three years, we've been able to, I think, find some keys to success in this case. And we have had improvements in her A1c, which I will show. But I just want to highlight the ones that specifically impacted her case in hopes that they will help you in your future cases. So first, and for Ms. Espy, getting her family involved and getting her into a more supervised setting was absolutely crucial to being able to move forward her care. Once her daughter realized the severity of what was going on and the risk of her driving with hypoglycemia or living alone with the risk of such, she actually had her move into her home with her. So she moved in with her daughter and her family, and that allowed for a lot more supervision over her medications as well as her diet. We also just took a step back and really took a patient-centered approach. We do this a lot in Care Plus and realizing that what the textbook says is not always what we're able to rule out, at least not initially when we're meeting a patient facing so many challenges. So we tailored her A1c goal and her treatment plan to what seemed realistic. And at first, when I met her, our goal was to get less than 10% because she had been over 10% for years. And, you know, first meeting her on a board question, it would be, you know, this patient needs basal bolus, maybe a pump, something to deliver her insulin more consistently. But in her case, just wasn't feasible at the beginning. And so being realistic about what was the goals for her and what a treatment plan, a safe treatment plan looked like. And then soon after I met Ms. Beth SB was when we started getting the CGM technology more utilized in our patient population. And so we started to use one for her, and that was extremely helpful, both from the standpoint of monitoring for those hypoglycemic episodes, but also helping her start to understand what her impact of diet and lifestyle interventions were on her glucose control. We're very lucky in our team and that we were able to start implementing more frequent visits for her, including weekly visits where she would come see our nurse or provider every week. We would administer her GLP-1 agonist to ensure she was getting that therapy. We would monitor her insulin administration so we could make adjustments as needed. And then we would get a CGM report every week and we could actually make small titrations in a safe manner until we could get her at better control. Sharing care with endocrinology and our certified diabetes education specialists were huge in this case. I cannot highlight that enough in my short time. But they were, our certified diabetes education specialists came up with some very unique ways to help make a CGM more useful. In this case, when we first started using the CGM for Ms. SB, she would come back and we would have like 5% of data from the last week because her CGM ended up being in the other room or another house. And so our certified diabetes education specialists helped come up with a strategy to have a bag around her neck where she carries her receiver with her. And so we actually got our glucose data. There also became an issue with her actually recognizing her hypoglycemia alarm overnight if she had prolonged episodes of hypoglycemia. So there's some new technology including a bed shaker or a monitor that can be in a family member's room that alert them when her values went low. And endocrinology was able to eventually empower us to get out of that treatment inertia and restart short-acting insulin once she was in the supervised setting and in a safer environment to do so. And last was just making short-term achievable goals for lifestyle intervention. So when I first met Ms. SB, she had had all the education on diet, carb counting, what to eat, what not to eat. And when I met her, I soon realized that that actually left her not knowing what to do at all and that she was very overwhelmed. So we pared it down to much more achievable goals. When I first met her, it was no bread for breakfast. We could understand that. She had for many years eaten a sausage and egg sandwich every single morning on loaf bread for breakfast. And so we start small and make those actually achievable goals. And we made a lot of progress once we got there. So last, I just want to end highlighting her A1C trend over the time that I've known her. So again, this is where I met her in 2021. And this drastic decline in her A1C correlates with much of what I talked about, but specifically her moving in with her family, starting to have weekly visits with our team and utilizing a CGM. But as you can see here, life changes, right? And this correlated with her daughter getting a second job, having less supervision in the home. But we used what we learned previously and what helped with the challenges she was facing. And we were able to implement, find a new family member to help her when her daughter was at work and added the short-acting insulin. So her A1C has now improved again, but it's a journey. And the beauty is we've learned from our prior successes and life changes, but the information we gained from that, we can utilize again. Great. So I think that's a great example of it takes a village to take care of patients with diabetes. So we are going to move on to our endo family. And I challenged Dr. Uso as an endocrinologist to kind of give us her thoughts of what would be the ideal referral that she would receive from a primary care provider. Yeah. So that's a great question, Paige. And I really thought about it deeply. For me, it's really about data. So the more data that I have readily available, the better recommendations I can give in that initial consultation. So ideally, before a patient gets to us in endocrinology, they have the ability to check their blood sugars, whether that's with a glucometer, with a personal CGM, that's even better. And if neither of those are really great options, they can even wear a professional CGM because having that data readily available kind of reorients my mind so I can figure out where the issue is, where are the high blood sugars? Is it a fasting issue? Is it a prandial hyperglycemia issue? Are there lows that I need to address when I'm tailoring my regimen? So having glucose data is key. Lab data is also key as well. So having a recent A1C, and that's really important. Once I've figured out what my target A1C in it, that's different for every individual depending on age and comorbidities. But I can then calculate how much A1C lowering that I need, and I can pick medications that are most likely to help me be able to achieve that goal. Also having BMP, so knowing what their renal function is, is also helpful in guiding my recommendations because a lot of these diabetes medications, we have to take into account renal function. And so that's really important for me in terms of what's the ideal endocrine consultation visit. And I talk about how data is important to have. And so one of the best ways that we can get data is really using our support multidisciplinary team. And so having individuals meet with our certified diabetes educators prior to even coming to see me as an endocrinologist. So the ideal referral in my mind is at the same time you refer to an endocrinologist also referring to our CDCESs because at that initial visit with the CDCES, not only do they most of the time have quicker availability, but the CDCES can gather a lot of information, can see what the blood sugars are, can see what the diet is like. They can teach them how to use a glucometer, how to use their personal CGM. They can go ahead and connect the individual to our clinic portal. So that saves rooming time when the patient comes to see us as an endocrinologist at that initial visit. And so not only can the CDCES gather good data for us, but they can also provide good information to the patient as well. So teaching them how carbohydrates affect the blood sugar, what is a carbohydrate? Because we know living with diabetes is constant and it can't just be fully managed with just a visit every two, three, six months with a provider. And we really want to try and empower the patient to gain confidence in understanding what diabetes is, to know what their blood sugars are, how the medications work, and why we even care about having well-controlled diabetes so they can be self-motivated to achieve their best control. I'll go ahead and talk. Sorry, Paige, were you going to say something? Nope. I thought you were doing a great job and thanks for that plug for CDCES. You know, like I said, it takes a village and it takes a nice team approach to the patients. And I think patients are much more successful when they, if they do meet with an educator first and then go see you, I think they are more equipped to ask really good questions. And I think they are, you know, they've kind of got the shock a little over and they're a little bit more comfortable. So when they come to you, they can ask questions and they can, I think they're a little bit more successful as far as getting time and range quicker when they do that, when they can go through that steps-by-step approach. So one of the other questions that I wanted you to address is, you know, there's so many, so many classes now of drugs and diabetes. And thank God we have the ADA standard care mobile app. You know, you probably have all this in your brain, but when the educators or primary care is kind of working on the front line, sometimes we need to go to that little app and plug in some stuff and get the right algorithm, figure out what's our best approach for that patient. So if you elaborate on the medications, that'd be great. Yeah, no, that's a great question. A great point, Paige. And, you know, a lot of this information is really well organized on the ADA standards of care, specifically the chapter nine. There's a table 9.2 and a figure 9.3 that really nicely just kind of summarizes what the different glucose-lowering medications are and what population you might want to use each one in. And like Paige had mentioned, there's a very nice app as well that you can download, and it'll just kind of walk you through, you know, just putting in what the patient characteristics are and it'll walk you through what the best medication would be for them. But when I am trying to come up with a regimen, really two big questions that I want to ask is, you know, what is my A1C lowering goal? So how much of an A1C do I need this, you know, lowered? And that helps me determine what medications might actually help me achieve that A1C lowering. And then second, you know, what's my goal for cardiorenal risk reduction and weight reduction as well? And so, and the name of that app, it's just ADA standards of care. And you can just go to your play store and that will, you can find it that way. And so, it's important to know kind of both of these, you know, what is my A1C lowering goal and what's my goal for cardiorenal and weight reduction, risk reduction. And so, if my A1C's goal is to lower it by more than 1.5%, many individuals are going to need dual combination therapy, so more than just one agent. And so, if I'm going through the classes, you know, I think a lot of us metformin is one of our go-to first agents. And, you know, I think it's a reasonable starting medication for, you know, anyone newly diagnosed with type 2 diabetes, regardless of A1C, but knowing that if their A1C lowering goal is more than 1.5%, you're likely going to need an additional agent to metformin. And the most common side effect is the GI upset, but that tends to be better if I use extended release. So, that's really the only formulation I use when I'm prescribing metformin. And you can also do a slow titration. So, start at 500 milligrams once a day, do that for a week, and then increase it by 500 milligrams every week until you get to the goal dose, depending on what their renal function is. If their GFR is greater than 60, then you can get up to 2000 milligrams a day. And if at any point they're not able to tolerate the next dose up, we just tell them to go back to the previously tolerated dose. The next class, the SGLT2 inhibitors, and they are really good. They work by inhibiting glucose reabsorption in the nephrons, and so you have glucoseuria. So, I do tell people that you're going to be urinating more, and so it's important to increase your water intake so you don't get dehydrated. There is the risk of UTI and yeast infection, especially with A1Cs greater than 9% to 10%. So, you really want to be cautious if you're using it in that patient characteristic. And I also tell people during critical illness or prolonged periods of fasting, you definitely want to hold the SGLT2 inhibitor until you get over that. We know there is a risk of euglycemic DKA, though this is rare, but it does happen. And a lot of times, I'll just go ahead and prescribe urine ketone strips for patients to have at home so that they can check it themselves if there is a concern, and then kind of follow up with the results. And one of the big things is that this class of medications have shown really significant cardiovascular and heart failure benefit, reducing risk of hospitalization from heart failure and reducing risk of cardiovascular death as well, and then also reduced progression of diabetic kidney disease. The next class I'll talk about are the GLP1s, and I'll just group it in with the dual GIP and GLP1s as well. And so, these class, they help the body produce more insulin, and they're fairly potent, probably only second to insulin. And so, you can get as much as 2% or more lowering of the A1C. And they've also been shown to reduce major adverse cardiovascular events and also reduce heart failure hospitalizations as well. And then there was a paper that came out earlier this year showing kidney benefit as well. So, semaglutide reduced the risk of kidney disease events and deaths from cardiovascular causes in patients with type 2 diabetes and chronic kidney disease. And we know very well that this class also helps with weight loss. So, if that's a big goal to lower the weight, then this is a great class as well. But it's also important to note, and I work at the local VA, and so I have a lot of older patients. And with any weight loss, there's also not only a risk of losing fat mass, but lean body mass as well. And so, I try to encourage people when I do start them on this to maintain protein intake, if not increase it, try to do as much resistance training as you can so that they don't have as much of a loss of lean body mass as well. So, this class contraindicated with self or family history of medullary thyroid cancer or pancreatitis. Most common side effects are GI. And so, another one that you want to do a slow titration up. I'll talk about the DPP-4 inhibitors briefly. Contraindicated with pancreatitis, typically renally dosed. It's weight neutral, not as effective as the GLP-1s. And so, that's the other thing. They work very similar to lead to GLP-1, so there really isn't a reason to do both at the same time. TZDs, they have a benefit in those with MASH or the metabolic dysfunction associated steatohepatitis. There is a risk of fluid retention and weight gain, and they can increase the risk of heart failure exacerbation as well. The next classes are the sulfonylureas, and they actually can promote weight gain as well. They have a higher risk of hypoglycemia. So, I tend to try and avoid this class and those who are at increased risk. So, older adults or those with CKD, and also those who are already on rapid acting insulin. And then lastly, insulin is one of the most potent medication that we have to treat diabetes. And because of that, there's the highest risk for hypoglycemia. So, we really want to make sure individuals on insulin are prescribed glucagon as well. And we consider starting insulin for those individuals who have severe hyperglycemia and potentially present with weight loss, ketosis. And definitely, it's fairly common to start at least basal insulin when someone has an A1c of greater than 10 or blood sugar greater than 300. Great, fine job. Okay, we're going to move into probably my personal favorite. No offense to anybody on the panel, but that would be technology. So, take it away, Carrie. Awesome. So, I too am obviously biased. As Paige said, I am a technology lover for our diabetic patients. But I think Dr. Koontz and Dr. Valente did a really good job of showing us some examples of how they've used the technology in their clinics, even with these more challenging patients. But the big question is in primary care, how do you do that? How do you actually start integrating these CGMs into your daily practice? And so, I see really three main ways that we start to integrate that. And it starts with getting the patients ready. And really using our certified diabetes education specialists is our number one way to accomplish that. And that can happen before they even see their medical provider that's going to be managing the diabetes. And as Dr. Uso said, I encourage that coming from primary care, you know, get them in with this great support. If you are in a region that's maybe more remote, or you don't have that support closely, I'm going to talk a little bit about how you can get the clinic nursing staff involved as well. But definitely use your education team if you can. Getting the clinic ready is going to involve both getting yourself ready, but then also getting your nursing team ready. And so making sure that you have all of your clinic accounts set up, so your Dexcom Clarity, LibreView, your ADMS Pro for the new Eversense sensors, and then kind of helping the nursing staff to integrate that into their rooming process. So in our clinic, the nurses that I work most closely with do essentially a version of a pre-chart, right? We look at a patient chart, we try to familiarize ourselves with them, and they're doing the same thing. So going through each morning, or maybe, you know, the night before and looking to see which of our patients that we're seeing tomorrow have technology, can I go ahead and download that and have it ready to save time during the rooming process? And if they have seen our wonderful education team, that is very easy to do. They're remotely connected, we can pull that right in and take a look. And then finally, getting yourself ready. And that means knowing your technology, that means knowing how to prescribe them, and then getting comfortable with the reports themselves. So how do I interpret it? How do I document that? How do I bill for it? And so we're going to dive a little bit more into that. So Paige had encouraged me to pull this, and I've actually adapted this and updated it a little bit to show just where technology has gone over the last year and why this topic has become so much more prevalent as we're learning about managing diabetes, because it wasn't until 20 years ago that the first personal CGM actually came on the market. And at that time, it was a tethered CGM, it only gave three days of data, but it was still giving alerts and alarms in that real time integration. And then we've had just this technology boom in the last 20 years with all of these new sensors coming out, lack of calibration, extended wear time, and then the decrease in size. And that has gotten really popular for patients. If you compare these current sensors to coins, right, that's what we see, we're looking at the size of pennies. And that's a really easy convincing tool to get patients interested in this, where there's not much that they have to actually show. So the four main groups that you will see on the market today are going to be your Freestyle Libre, your Dexcom, Eversense, and Medtronic. In the primary care world, where I see this most prevalent is going to be your Libre and Dexcom. Eversense, if you have a team in the area that's implanting those, that is the only implantable sensor, but unlikely in the primary care realm right now that we're going to have that available. Medtronic, primarily being used in pumps. And so if you are thinking about that for patients, probably getting them with endocrine. But our Libre is the Libre 3 and 3+, and then soon there will be the Libre Rio, which is going to be an over-the-counter sensor. The Dexcom, we're looking at the Dexcom G7 and the Dexcom Stello, which is the first of the over-the-counter sensors. And so I highlight these because you will probably see some of the older sensors still floating around the market. They are fine for patients to be using, particularly if they're locked into a receiver, like our Medicare patients. But if you're starting it, start the newest sensor. Set your patients up for success. Let them be on that newest technology. All right. So by now and through this, you've likely seen some of the ambulatory glucose profiles, these AGP reports. But I want to kind of walk through what we're typically looking at when we look at these reports. So first and foremost, we need to make sure we even have enough data, right? The patient hasn't just put the sensor on before walking in clinic. So we're looking for a minimum of 72 hours. Then we're looking at the averages and the variability. So we want to look at the glucose management indicator, GMI. That's giving us kind of that estimated A1c. And then the glucose variability, the coefficient of variation. And this is something that is really unique to sensors because it is completely lacking in an A1c. And I think we had a great example of that earlier where we don't really know when we get an A1c. Are we looking at great control or do we maybe have 10% hypoglycemia that we need to be addressing? So that is a really key feature. And then we're looking at time and range. So looking at our target range, 70 to 180 for most of our patients. And I'm going to touch on that a little bit more for how we can set those independent goals, just like we do A1c. And then finally, the tracings, right? Looking for patterns. And that's one of the biggest things. So in the example I have here, right, the pattern that we're seeing is that they're having overnight lows. And that's similar to the example we had earlier today where we can use that to actually make those therapeutic changes. All right. So when we're using these, as I said, we want to set a goal. We want the patient to know what we're looking at for them as well. So the one thing that you'll notice across the board here, we're looking at kind of our classic type 1 and type 2 diabetic patients on the left. These are going to be lower health complications, right, minimal concerns. We've got our older, more higher risk, right, so maybe have developed more complications and stage renal on that left middle. And then we go into our pregnancy classes. The one thing that's unique here is you'll notice that that critical hypoglycemia less than 54, the goal is less than 1% across the board. We just don't want to see it. That's a safety risk. We want to minimize that. In our standard patient population, though, the goal is to keep it less than 4%, right? We want to make sure that we're not having any critical lows. And if it's following a trend, we may still want it a little bit less than that. But when we move into our older, higher risk, we want to minimize that as well. And we want to keep that less than 1%. So if we think about that standard 14-day tracing, that's going to be less than about 15 minutes in that two-week period. So really helping them to minimize and have comfort. General time and range target is 70%. And that's going to equate with an A1C goal for most of our patients of less than 7%. For our older, higher risk patient population where we've maybe raised that A1C goal up, right, we've maybe said 8% is a reasonable place to try to keep this person. We need to also set that new expectation with the patient. And that's going to come out to about 50% time and range. And so our goal is 50% of the time, we want to keep you on that 70% to 180% and helping them to understand that. But also reminding ourselves, right, when we're dealing with these slightly more complicated patients, that we need to have reasonable expectations for them when we're looking at these tools. All right. So we've looked at the reports. We really want to get this into practice. And so where I see a lot of hesitation or lack of confidence a lot of time is, how do I meet the billing expectations, right? What do I need to put in my note? And how do I get insurance to pay for the time that I've placed working with my patient? You know, patient care is first and foremost. We've heard great examples of that. But we know in the business of medicine that we also have to get reimbursed for our time. And we want to make sure that it looks good on paper. You know, it's just a truth of the matter. So I'm including an example of what we are using in our clinic to document that checks all the boxes for payment from insurance. So the big things that we're looking at is, again, that 72 hours of data, evidence of interpretation. And it doesn't have to be a novel, right? We're looking at glucose variability, high or low, controlled, yes or no. And it can be as simple as that. And then what your interpretation of that is, what are your recommendations? And again, that can be very simple. I tend to include this as a separate note within my visit. It can be embedded within the visit note itself. That's really personal preference. And it doesn't have an impact. You do want to have evidence of that tracing, though, somewhere within the chart. So I tend to just snip it in. And so when we're looking at this, what we're looking at is, in fact, the 95251 CPT code. And so this is what you're going to be billing and adding on to your E&M code. So what that looks like is once you have dropped your visit charge, once you have added your documentation, you need to then make sure that you're adding what's called a 25 modifier. And that means that you have added a separate, significantly identifiable charge to your visit. The key part here, though, is it doesn't actually have to be your visit. This can be a dietician visit. This could be a pharmacist visit. This could be a certified diabetes education specialist visit. So your clinic can actually capture that revenue and time by utilizing this on top of some of those other team resources. And this is, again, where we work together. And I know Bobby's going to touch on that a little bit more in just a moment. So looking here, again, just kind of talking about how we can utilize that to avoid inertia kind of makes me think about how we can integrate the CGM and really maximize what we're looking out of it. So some ideas to think about with that primary care realm is, you know, could we put in an insulin titration clinic? Does that fit within the model of what we're working on? Can we work on pre-op glucose control in a different way with the knowledge that a lot of surgeons are actually accepting GMI now and in place of A1C to meet pre-op goals? And then I've included an example here of just really quickly escalating therapy with our new diagnoses. So Pearl's outlined here. So again, engaging your team, use your templates, interpret your report, and then bill for it. And so my final piece before we pass it on is just knowing how much this is worth. So one billing for 95251 is worth 0.7 RBUs. Doesn't sound like much, but if you did that just one day a week, or excuse me, once a day, four days a week, 48 weeks a year, you're looking at the equivalent to billing an additional 70 level four visits. That's about a week of work. So that really, I think, looks impressive. So I will leave you at that, but I really encourage everyone to pull this in. It's a great way to utilize your resources. All right. Thank you, Kari. So now we are going to learn actually how to do that by Bobbi Harmon. Thank you. Thank you, Paige. Today, I'm going to speak with you about showcasing your value as a CDCS and marketing your diabetes education program to primary care providers. This first slide, this is the education recognition program national benchmarks. And it kind of goes without saying that diabetes self-management education does make a difference. Patients are lowering their A1C, hospital admissions are decreased, and they're also decreasing their weight when they come to a diabetes education program. When you're showcasing and marketing your program to a primary care provider, it's important to share these national benchmarks, but also share how your program's outcomes weigh out to these national benchmarks. And in general, the CDCS is most commonly found in an endocrinology practice, but also the CDCS can bring a lot of value to the primary care team. For example, a primary care physician has 20 minutes or less maybe with a patient with diabetes. That is not enough time to cover everything about diabetes in that one visit. This is where the referral to a CDCS can bring value to that primary care provider by helping to carry out the care plan for that patient and continue the work of that provider in additional visits. So overall, the CDCS roles are integrating diabetes self-management education and support into the clinic setting, integrating education that addresses comorbidities such as cardiometabolic and weight loss, leveraging technology. I feel we truly are seen as the diabetes technology experts in the clinic. We also are promoting and integrating behavioral health. We optimize diabetes care with a quadruple aim, improve patient and provider experience, improve outcomes, and lower cost of care. Also, we do advocate for equity in patient-centered care. So the five times to refer to DSMT. I think there's a lot of, when you're speaking with primary care providers, a lot of times they don't know these five critical times to refer. And of course, it's at diagnosis, annually, for assessment of education, nutritional or emotional issues, when the patient develops new complications. For example, your patient comes in and has a foot ulcer. That's a definite refer to diabetes education. And also during changes in patient's life or care. Your patient comes in and they've lost their spouse. And now they are responsible for grocery shopping and meal preparation and planning. And this is where they will need support to be successful to continue to manage their diabetes. Also, when the patient is not at goal, if their A1C is above target, that's always a good time to refer to diabetes education. Or if you are adding a therapy that needs to be intensified, we can follow up on the patient for medication management. So also, in my experience with visiting primary care offices, there's an unawareness of the amount of education visits a person with diabetes can receive from a CDCES. This results in underutilization of diabetes education services. So, the Medicare benefit for diabetes self-management education is 10 hours of education and three hours of medical nutrition therapy within that first year of being referred. Each subsequent year, a Medicare patient can receive two hours of diabetes self-management education and two hours of medical nutrition therapy. So, this is also something that's really important to relate this message to your patients when you are thinking of referring to a diabetes education program. That it's not just a one and done visit. We're there to support them through managing their diabetes. We're not teaching just the same curriculum to each patient. It's very person-centered. And the CDCES is going to ask, what is most important for you to learn? Or what do you need the most help with in managing your diabetes? And we can tailor their education to meet their needs and meet them where they are. So, I think if primary care providers can give just a short explanation of what's going to happen when you see a CDCES, then more people would show for their appointments and then those patients would get to reap the benefits of the national standards. Okay. Blueprint for success. So, using a CDCES in your practice can be beneficial to the person with diabetes and also the provider. The CDCES can assess barriers and social determinants of health. They also will help your patient understand and implement the guidelines They also will help your patient understand and implement the care plan. And this in turn can ease the provider's workload. We can continue to see them several visits in between and help meet those A1C targets. Okay. So, one way in our clinic that we are using this blueprint for success is through referrals for technology assessments. Whether that is for CGM or insulin pumps. So, our providers in the clinic will send a referral for just technology assessments. But for today, I'll use an example of our CGM process. So, a patient comes in and they're interested in CGM. They'll meet with one of our CDCES and we will assess any barriers that they have to technology. We're going to make sure that their smartphone is capable for remote monitoring. We could identify any dexterity issues. We have sample and demo CGMs that they can practice with. And the CDCES is going to review all the features of all CGMs in an unbiased opinion. And this is going to help match the CGM to the patient. Because we want them to be successful. We want them to like the CGM that they choose. Also, I like to think ahead in my patient's care. If an insulin pump is in the future, then we need to choose a CGM that could be integrated with that insulin pump. Although most CGMs are going down that path, but not all are there yet. So, if the patient is interested in smart pens or insulin patch delivery devices like C-Cure or Vigo or an automatic insulin delivery pump, we want to make sure that we choose the right technology that's going to make all of this work for them. And in our clinic, the CGM order is handed to our providers or we do utilize an online platform parachute to send orders to durable medical equipment companies or Medicare patients. And at the end of this visit, the patient is provided instructions to please call the clinic when they receive their supplies. And then they are scheduled with in our CGM group training class. During this class, CGMs are placed. We talk about the data they're going to be receiving, interpreting trend arrows. We may talk about how to troubleshoot your CGM. We talk about adhesive issues, anything that I can predict that they might have questions about later. At the conclusion of the class, they're all connected to the clinic for remote monitoring. And then in two to four weeks, each patient is scheduled with a CDCES for a one-on-one visit. And there we will download the device. We'll review time and range targets. We'll talk about all the data that they've been receiving. And then a lot of times nutrition counseling comes up in this appointment. They realize that they need to make some changes to their diet. and then we also will do medication adjustments per our protocol in the clinic. At the end of that visit, I will put a report into the media tab in our EMR, and I actually will charge for the personal CGM training. It's billing code 95249, and then I route these reports to our providers and give them the opportunity to interpret the CGM, and they can bill the 95251 as Carrie was telling you about. Sometimes if they feel their therapy needs to be intensified further, they'll route the patient back to me, and I will either call the patient with instructions or have a video visit with the patient or even bring them in for a one-on-one if they need in-depth instruction for medications. So we are going to jump right into questions. Bobbi, do you have anything else before we do that? Oh no, I was just going to say just in conclusion that if you are a PCP in the audience that you use the ADA Standards of Care app and find a program, a diabetes education program, and start using your CDCESs, if you are an RD, an RN, a PharmD in the audience, and you're thinking about becoming a CDCES, do it. We're very needed, and you can definitely improve the lives of people with diabetes. Well said, well said. Okay, so we're going to dive into these questions because that is a very important part of this for us is to answer your questions. We have the first question. It says, my father has type 2 diabetes. He was recently placed on Ozempic 0.25, Lantus 20 units at night, CGM with the Libre 3, Humalog sliding scales. His A1c went up from 8 to 10 after Ozempic. He's in therapeutic range less than 50. He is, he's in therapeutic range less than 50 percent of the time. I don't know how often he gets in the hypoglycemic range. He eats Vietnamese food, often postprandial glucoses, or in 180s to 200s. Would love to hear your thoughts. Thank you. Who wants to tackle that? I can give it a shot. I guess, you know, obviously we don't have all the information, but when I hear, you know, postprandial blood sugar is 180s to 200s, but the A1c is 10 percent, you know, there's, you know, I wonder could there be some type of disconnect? Because sometimes things can interfere with the accuracy of an A1c and some things can interfere with the accuracy of a CGM. So, you know, asking some of those questions. Also, we don't really, he hasn't really gotten to the gold dose of Ozempic, so potentially as they, you know, increase the dose, numbers may get better. And then the fact that just on the Humalog sliding scale, you know, could you be playing catch-up when you're doing the sliding scale, not having a mealtime insulin dose? So, those are just some of the thoughts that go through my mind, but, you know, there's a lot of information that we don't have. Gotcha. I've had the same thoughts. Maybe we just need to hang out for a little bit longer and get a little bit more Ozempic on board. Next question is, please comment on a whole food plant-based diet as a baseline for diet management for type 2 diabetes patients. I am a big proponent of eliminating animal products to vastly improve insulin sensitivity and could potentially replace the focus on carbs. That has to be a Bobby question, unless anybody wants to take that. I do think it's doable. You just want to make sure that you are incorporating some types of maybe vegetable proteins into your diet to keep things balanced between carbs, proteins, and fats. All right. Dr. Issa, this next one is for you. Curious your thoughts on discontinuing metformin when the patient starts on Monjora and what protocol do you follow? Yeah, that's an interesting question, and I'll kind of reference what I said during my portion when I'm trying to figure out what a good medication regimen is. I first figure out how much do I need to lower the A1C and then what cardio-renal weight reduction goal do I have. If the concern with being on both metformin and terzapatide is potential for GI side effects, I'm not sure if that's what the issue is because you can definitely be on both at the same time. But if I'm already at my A1C goal, then am I getting any benefit from the metformin? So those are kind of the questions that I would ask, and I kind of don't have all that information. But in general, I think it's fine to be on both metformin and terzapatide. If you're concerned about GI side effects, then yeah, you may need to take one off. But yeah, those are kind of what I'm thinking. Have you heard of the new Abbott Supplement Protality that is aimed at individuals on GLP-1 weight loss meds to help preserve muscle mass? And if your patients have used it, have you had any success with it? I have personally not used it. I know there's a lot of research going into medications that it can even help preserve muscle mass when you are on some of these weight loss drugs. So I can't really personally speak to experience. I don't know if anyone else on the panel has experience with it. Are there any instances where you would try a GLP-1 RA in a patient who has had pancreatitis in the past? Sure. I think knowing the etiology of the pancreatitis is key. For example, if it was gallstones, but now that they've had their gallbladder removed, then you've kind of removed the inciting factor. And so I think it would be fine to be on a GLP-1 and have that history of pancreatitis. However, if it was related to hypertriglyceridemia and their triglycerides are still off the chart, then you probably want to be cautious with that. So yeah, but there are definitely some instances where I'll go ahead and do a GLP-1 with someone with a history of pancreatitis. So it's really important to know the etiology of it. Great. All right, Carrie, you're up. Does the provider have to enter the CPT code for CGM interpretation or can the CDCS? Great question. So it is the provider. So the only people that can enter that code are physicians, nurse practitioners, and PAs. Do you know how this works in the, in FQHC, I'm assuming is the federally qualified, let's see, health centers in that world of billing? I would assume it would work the same way. Do you have any thoughts on that, Dr. Uso, with the VA? I believe it would work the same. I am able to bill for my CGMs when we're in CPRS, but, you know, it's a little different in terms of, you know, we don't really do RVUs, but it's just a way to keep track. But yeah, I'm able to document that I'm, you know, interpreting a CGM. If the question is alluding to who pays for it, commercial insurances typically do, but Medicare and Medicaid, certainly Medicaid within North Carolina, but I believe fairly universally do pay for that interpretation. So the next question is, I thought 95251 was only allowed to be billed once a month. That is correct. So it is only billable once a month. Got you. This is probably a question for our ADA representative. Will the slides be available? The text slides, especially. So we'll have to, we will, I'm sure in the chat that someone will address that question. The next one regarding the five critical times to refer to CDCS, you said 10 hours within first year of being referred. Does that mean 365 days from the date to the first CDS visit or in a calendar year, January to December? That's a very good question, Bobby. Yeah, it starts at the date of the referral. So if the person's referred in May, it would expire the next May. Gotcha. What's the best resource to find CDCS for independent general practitioners? They are not connected to a health care system. I've found that databases are not always up to date. Very good, very good question. Any thoughts on that, Bobby? I guess to the ADA. I think the ADA will help you with that. And the ADCS actually, I think, has an educator finder on that website. I'm almost like 90% sure they do. Yeah, the ADCS is, the CDCS is kind of our governing body for our education and certification and whatnot. And I think probably our ADA rep can put a link to that, the ADCS website in the chat, if she will. Hi, for a clinic or center to be reimbursed for DSME, is it a requirement to have an RD on site? That's a very good question. Is that me? That is you, Bobby. That is all you belong, Mrs. Coordinator. And I know you know the accrediting powers at ADA well. No, you are not required to have an RD. You could be a program with all RNs, or you could be a program with all RDs. As long as the coordinator is a CDC, CDCCS. Right, there you go. That's a long new title we have. You know, at one point in time, Bobby and I used to work together. And what we had was we were very fortunate because we had a team of RDs, RNs, and PharmDs. And we all knew that we worked together and kind of referred to each other based on our skillsets to actually maximize touch points for the patient. And it was really nice to be able to utilize services across the multidisciplinary team. Because, you know, there were things that, you know, if I had that patient that was newly diagnosed, and they had kidney disease, I was, I can get them on the anatomy and physiology and the injections and all the medication. And then I looked at him and I'd say, I am going to refer you to a co-worker. Her name is Bobby. She's an RD. And she is going to help you get through this diet. Because this is going to be probably a little challenging, but she's going to make it simple. So it's always nice to have a team. We were kind of spoiled in that respect. How do you bill for a CGM training class? What codes do you use? Oh, for the CGM training class, initially I billed the group code G0109. And then when they come back to see me as a one-on-one, that is where I will use the CGM billing code 95249. Because you do have to have 72 hours worth of data to use that code. How do you encourage or convince patients who aren't monitoring their blood sugars to do so? Anybody can take that question. That has a great strategy. I mean, I'll touch on it as the tech person. I give them alternative ways of checking. You know, I think a lot of those folks who aren't giving me data don't want to understandably be sticking their fingers constantly. It's not comfortable. And they just prefer not to, or it's just inconvenient. And so usually if we can do even just a trial, right, even if they're a little bit hesitant, but we can get them to commit to a couple of weeks. And by the time they come back to us, it was a life-changing experience. They love it. It's been great. And they're ready to move on with their personal prescription. So I just give them alternative ways to do it. Alternative ways to do it. Okay. Any suggestions for hearing impaired patients who have difficulty hearing the alarms when sleeping? This would be potentially a case where the Eversense could be a really good fit. It has an on-body vibration. So if that is a resource that you have in your area, but beyond that, I do have a lot of folks who have just their cell phone set up with the adaptive technology. I wish that I could say that the receivers themselves were set up better for different disabilities, but they really aren't. But on cell phones, if they're using some of the different adaptive technologies, they can still get the same flashing or vibration. So I've got folks that'll, you know, have it on the bed so they can feel it. So really the cell phone use, I think is the biggest change or push that I would make. I'll also comment. I think there are some other many products available, but one is like a bed shaker. So it works by Bluetooth, connects to the receiver. And so when there's a low, it will actually shake the bed. There's many of those available. And then there are also some monitors that look like alarm clocks that go in the family's room and will alert when there's lows, it will show the actual patient's blood sugar and their trend arrow on that receiver. So a family member can have it as well, or the patient can have it. It displays their number larger. So a vision is an issue. I've found that to sometimes be useful. Oh, great advice. Great advice. Most insurance companies do not cover CGM. As you said before, most insurance companies do not cover CGM. And most of the data you provided is based on CGM. How can we manage people with diabetes who can't afford CGM? I'm going to disagree with the statement slightly, because I do think a lot of insurances have picked it up. Yeah, lately, I think they have. Yeah. But if you are running into that, or if you have a candidate that just doesn't have good coverage, we do have the new Dexcom, Stello, and then upcoming Libre Rio, which are over the counter. And then there is a self-pay option with the Libre 3 and 3 Plus that they can activate that brings the price down to 75 a month, if that's doable. There may be cases where, you know, even that they can't do. And so you're looking at other resources. But for the most part, you can find a way to make it work. Gotcha. And a follow up from the Metformin question, it was more of if A1c is at goal and both Metformin and Majora are tolerable, is it necessary to be on or stay on Metformin based off mechanism of actions? No, I don't think so. If your A1c is at goal, yeah, I think you don't need to be on the Metformin. And if you can titrate up the terzepatide even more, that, you know, that'd be great, too. Great. Best resources to become a CDCES? Bobby, you want to tackle that? Sure. Of course, at the certification board, the CDE, that's correct, right, Paige? Right. You can see all the requirements for becoming a CDCES. And also, they have study guides available on that website. Through the ADCES, you can purchase study guides. And also through Beverly Tomasian. She's a great educator and devotes a lot of time into CDE boot camps. That you can do as self-study pace on your own. But I'll say I used one of those when I became a CDE and I passed the test. Yes. And I will tell you, as somebody that's been in nursing 40 years, when I took my nursing boards, it was a two-day event. And that certification, those materials helped me a great deal. I passed mine as well. And I was very grateful for those study guides. So, they are very, very good. Has anyone used the CDCES through Cornerstone for Care? I have not. I like that program, but I have not used the CDCES through them. Is there a conflict of interest if the referring provider, APRN, is also the DSMES educator? Oh. I do not know the answer to that, Bobbi. That's a very good question. Can you say the question again? Is there a conflict of interest if the referring provider, an APRN, is also the DSMES educator? So, you can't refer to yourself, can you? They're saying the APP also has their CDCES. I'm assuming that's what she is saying. I don't know the answer. I do not either. And I am so sorry. We do not know the answer to that. But you know what? We have a great body of people at the ADA from our program that anytime we have a question like that, we will call them and ask them or we email them and they always have answers to really hard questions like that. So, honestly, I would defer you to the ADA team that license education programs across the country. They are wonderful. There was one more question that I am going to try to get in. It was put in the chat. um let's see i'm trying to look for mary sorry guys i have to go through all the different links I'm a nurse practitioner in a CD, see as there is no issue, I am a primary care provider and see both consults and my own patients. So some nice person answered that in the chat. So everybody that's participating, make sure you look at the chat because some of these nice people are answering some of the questions that we had, which is great. I was looking for, first thing was Mary, her question that she said she put it in the chat and this little chat section has blown up quite a bit. I can read Mary's question for you if you like. Oh that'd be wonderful. Sure, so Mary said I have a question, I have a Dexcom 6 and have been having a local reaction to the adhesive, redness, itching, and blisters. I have used NuSkin and Opsite. Any suggestions? Would Flonase help her? Flonase. Just make sure you let it dry before you put it on, but Flonase has helped a lot of patients of mine. Wait, y'all have to expand on that for the primary care providers. We thought that was a joke. Flonase, right, it's the nasal spray, antihistamine steroidal spray, but because of the format of it, it's not in a lotion or cream and so it can be applied as a barrier without impacting the adhesion. And so you can spray, once you've alcohol prepped, spray a couple puffs on the skin, but then as Paige said, let it dry completely. And then you can either top that with a barrier wipe or try just that by itself. But the kind of three step would be Flonase, barrier wipe, hydrocolloid patch, and then pop the sensor on top of that. The alternative though would also be trying a different sensor. The G7 does have a different adhesive than the G6. Thanks everybody for joining us. We really appreciate your attendance. Make sure you do all the work to make sure you get your CEUs and I'm sure we will be showcasing some interesting webinars next year in Diabetes is Primary. Thank you all that participated in the panel. Appreciate it.

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