Hi, everyone, and welcome to today's session entitled Overcoming Therapeutic Inertia Together. I'm Sarah Bradley, Senior Managing Director of Professional Engagement and Education at the American Diabetes Association, and we welcome you to today's webinar. Through ADA's Overcoming Therapeutic Inertia Initiative, we've been able to partner with several organizations to address the challenges of diabetes care at the patient level, at the clinician level, and at the health system level, and we're joined today by several experts from associations who represent the entire diabetes care team. So let's meet the panel. So I'd like to welcome with us, we've got Debbie Hinnin with AANP. Debbie, can you say hello and tell us where you're from? Greetings from Colorado. I'm an advanced practice nurse and certified diabetes care and education specialist at the University of Colorado Health in Colorado Springs. Thank you. Great. Thanks, Debbie, for being here. Gretchen Yusuf. Hi, I'm Gretchen Yusuf. I'm a registered dietician and a diabetes care and education specialist from Washington, D.C., and I work for MedStar Health, and I'm representing the ADCES. Great. Thanks for being with us today, Gretchen. And then Jonathan Little with the American Pharmacists Association. Yes, thank you. Hi, everyone. My name is Jonathan Little. I am a pharmacist and I'm with the American Pharmacists Association. I am the research and innovation project management specialist with the American Pharmacists Association Foundation. Very happy to be here. Thanks. Yeah, great. Great to see you and be here. And then also we want to introduce Mary Ann Klee-Thermos. Hi. Thank you, Sarah. It's a pleasure to be here and welcome everyone. I am with the American Society of Health System Pharmacists where I'm director of medication safety and quality, a passion of mine. And I'm coming to you with this presentation with 20 years of ambulatory care experience embedded in clinics or physician offices. And I actually currently am in Lake Leelanau, Michigan. Sounds wonderful. It is. Well, thanks to our panelists for being here today. We also want to thank the associations who've been working with us so closely on our Overcoming Therapeutic Inertia Initiative, AANP, ADCES, the American Pharmacists Association, and the American Society of Health System Pharmacists. Thanks so much for your support. We also want to thank the supporters of our Overcoming Therapeutic Inertia Initiative, strategic partners AstraZeneca and Sanofi, also our supporting sponsors Merck and NovoNordisk. Before we dive in, we want to define therapeutic inertia just so we can level set and know what we're discussing today. So therapeutic inertia in diabetes care is when there is a delay or some type of inaction to initiate or intensify therapy when glycemic treatment goals have not yet been met. This problem can lead to a whole host of challenges for people with diabetes, for their clinicians, and for the health systems. Last year, the American Diabetes Association conducted a meta-analysis to investigate what affects interventions to overcome therapeutic inertia we're working on glycemic targets for people with type 2 diabetes. And this review found that the most effective approaches for mitigating therapeutic inertia and improve A1Cs were those that empowered healthcare professionals like pharmacists, nurses, and diabetes educators to initiate and intensify guideline-directed treatment. So to learn more about this work, visit therapeuticinertia.diabetes.org. We want to spend the next 45 minutes or so talking about specific strategies and recommendations that can be implemented in your clinic tomorrow. And we want to hear from you, so please feel free to drop a comment or a question in the chat. I see we've got some amazing people already from all over the world, California, Bowie State. We've got Mexico. Welcome, everybody, and please keep those comments coming. So let's dive in with our first question to the team. Tell us more about your role. Who are you? What do you do on a day-to-day basis, and how do you leverage a team-based approach to overcome therapeutic inertia? Jonathan, we'll start with you. All right. Thank you, Sarah. So as I said, I do work for the American Pharmacists Association Foundation. However, I also have five years' experience at a community pharmacy that I still work at here in Oklahoma City. And so I believe that the community pharmacist has a very large role on the health care team, and in terms of overcoming therapeutic inertia, we can make a very big difference. You know, obviously, when you think of a community pharmacist, you know, we have access to, of course, the patient's medication list and medication history, adherence rates, co-pays, things like that, of course, and that's all very valuable. But I believe one of the strongest things that the community pharmacist brings to the health care team is actually just that relationship that we have with our patients. Obviously, patients with diabetes often have multiple medications or maybe even multiple conditions and therefore even more medications. And so we tend to see these patients very often. The community pharmacist is known for being very highly accessible. We might see these patients every single month or more. So we have a lot of touch points with these patients, and we tend to form very strong relationships with them because we see them so often. So you know, at the pharmacy I work at, you know, there's certainly patients that I know they're, you know, they're a whole family, their children and their grandparents, everybody. So that relationship is genuine. And I think that when you form that trusting relationship with the patient, you can really make a difference in their care by understanding them, understanding them a bit better. And thereby you can ascertain and glean things about their life that are valuable to know when it comes to treating them. So for example, if a patient is constantly asking for their medications to be delivered or sent by mail, you might be able to engage them in conversation as to why that is. And perhaps there's a social determinant of health, you know, thing going on here in that they lack transportation or reliable transportation. So learning that and communicating that to the team really is valuable information and can be useful for other team members to know as to why they're maybe missing certain appointments throughout the year. Or basically, you can address that as a team and figure out ways to meet that patient where they're at. Yeah, that community connection is so important. Thanks, Jonathan. Okay, what's your role and how do you leverage a team-based approach? Thank you, Sarah. As a nurse practitioner and an educator, I'm kind of in the position of the best of all worlds. And so while I have access to a multidisciplinary team, because we have an ADA-recognized program, I think most of the providers out there do not. And as the meta-analysis highlighted, it's so important that we help create that team. So while my position is clinical and education and now, of course, a lot more virtual than it was before COVID, I can, because of that virtual opportunity, see people that are four or five hours away who would not be able to drive through the mountains four or five hours to come for a visit, whether it's a clinical visit and or education, or a combination of that. So leveraging that team, even though we may have access to people, the vast majority of the prescribers and PPAs and primary care do not have that team. So making a referral for education is the most important first step. You may prescribe Metformin extended release, and you may get that question, what do I eat? And I think that's the first question all of us hear, certainly I hear. And so it's incumbent upon us as prescribers to help people get started. So it's more than, hey, don't eat anything white. It has to be some tips that are basic tips, whether it's the modest carbohydrate and don't eat sugar and use the plate method. But that referral to the comprehensive diabetes education team is critical. Not just the dietician, that is not enough. So that initial referral helps leverage the team. And ADA, of course, tells us, gosh, there are four really important times that we make a referral for diabetes education. Not just when people are newly diagnosed. It's not one and done. Annually that should be done. And Medicare beneficiaries have not just two hours of education, but two hours of medical nutrition therapy. And use of that benefit barely is in the double digits. It's terrible. We're not doing it well. But certainly crisis in people's lives, big changes, and or medication changes. When somebody starts insulin, the whole fruit basket is upset. So very important that we leverage that team, become best friends with the diabetes educator. But it's important that we leverage all of those team members, not just the ones you see here today. You have to be developing those alliances with other subspecialties as well. Yeah. Thanks, Debbie. And thanks for pointing out those four critical times for DSMES referral. Really important information. Marianne, let's go to you next. How do you leverage team-based approach? Well, I'm going to talk about two experiences. And I'm kind of talking about an embedded pharmacist. My first one was 10 years working in a clinic building where I was not necessarily embedded in every office, but that was referred patients that were complex and often diabetic patients. And so my work was to look at the inertia that they were having where they were not getting done. And the second one was actually in a team that included a physician, nurse practitioner, coaches, physical therapists, social workers, pharmacists, and dietician. And so I really want to talk about that role in both places. And it really is the focus specifically on medications and is the problem the patient having due to medications. And we can call that inertia. Oftentimes it's many things. They're not moving forward because of side effects, it's not working, they're not taking it right, they're not getting it, all of those things. But I have that focus on is the patient's problem medications? And there really is no one else totally focused on that. And my best example, I'm going to give a little story where we had a complex patient and the physician and I decided to see the patient together to kind of limit the time for that patient. And so he said, go first. And I started asking the typical questions I did of somebody who's on nine medications. And he was typing away furiously as I was talking. And then he went into his questions and did his physical exam and we put the plan together. And I asked him afterwards, what were you typing? And he said, I've never gotten more information out of a patient than what I got when you started asking questions. And I thought, as I thought about it, he's a great physician, very capable, very well respected. And I thought it's just that our mindsets are different. His mindset is going to the diagnosis and thinking about his physical exam and his labs he's going to order. And my mindset is getting all the data I need to be the sleuth as to whether medications are causing this problem. Yeah, that perfectly illustrates the different roles on the team for sure. Gretchen, over to you, what's your approach to team based care? So I'm Gretchen Yusuf again and I am the director of our Diabetes Institute. So I work with our diabetes education programs, our 10 programs across D.C. and Maryland and also quality initiatives for our system. And back in 2014, our system identified that we do have therapeutic inertia that is really a challenge and they wanted to break it. So we started working with our primary care and our primary care told us we do not have enough time to work with our patient. We have patients scheduled every 15 minutes. They're not getting to see the diabetes educator for whatever reason. The diabetes care and education specialist for whatever reason. So we start working and we designed a program where the patient would come in for two intensive visits with the diabetes care and education specialist. And to Debbie's point, when she mentioned about the four times of education, most of these patients never received diabetes self-management, educational or medical nutrition therapy. And some of them had diabetes up to 20 years. So the educator, really the diabetes care and education specialist really worked with them to identify barriers to self-care and specifically to medications to find out why they weren't taking their medications. And, you know, we found a lot of times it was social determinants of health that impact it, like they couldn't afford their medication. But oftentimes patients were placed on medication regimens that may have been perfect by an algorithm, but really wasn't perfect for their life. So we really focus on working on plans for patients that work for their life. And again, it needs to be something they can afford that they can live with. Many patients aren't going to take three injections a day, but they could take another medication like a GLP that would would be able to cover them. So we work closely with those patients and then we work. We pass these patients on for another 10 weeks with our nurse practitioner for intensive medication management. And so we found with the communication between the pharmacist, the diabetes care and education specialist and nurse practitioners, we have really been able to move the patients along. And the providers are very happy that people with diabetes are happy. So we've had a very good experience with this one team based program. Sounds wonderful. We hear all the time. Time is an issue. Those short visits did not allow for a lot of time for conversation. So thank you for that. We've got more people joining us. Kansas, Oregon, Illinois, India. Welcome to the webinar. A quick question, Debbie, I think this is to you. And I see there's already answer in there. But do you just want to give a quick answer? Are you able to bill for those telehealth visits? Yes, telehealth visits are indeed billable as a chronic care model as well. If you're doing short visits, that would add up to a monthly billing for some quick follow ups. So so, yes, we've had some very nice changes in the last couple of years that let us be able to survive doing this. Well, good. Yeah, thank you. And so, Debbie, we're going to kick the go ahead, Gretchen. So I just I just wanted to mention that we also started billing for the remote patient monitoring codes as well for those short visits that would not be considered an evaluation and management code, but could be an RPM code. And, you know, Medicare covers that. So that's what we're finding so far and some other commercial insurances. Coding billing always is a big, a big challenge. Sorry, Debbie. Go ahead. Education as well can be filled, billed virtually. So our program is hybrid with both live programs and virtual programs. And with our initial assessment, we try to work with the patient on where they are most comfortable, where they'll be most successful. Great, thank you. So let's get into the meat of this about the strategies, the specific strategies that our audience could implement to overcome therapeutic inertia. You know, Debbie, let's start with you. You know, what what is that maybe one or two strategies that you utilize that our audience could also use? I think speaking from a prescriber perspective, it's very important that as you pointed out, that 15 minute visit or maybe it's 30 minutes for a nurse practitioner visit. That has to be utilized very efficiently. And so the project that I've been able to help with AANP work with is to develop a tool for critical conversations. And that's based off of the ADA's therapeutic inertia project. And and the conversations circle around starting the conversation. You haven't done anything wrong. Diabetes changes. You will need more medications as time goes on. These are conversations all disciplines need to be comfortable with, regardless of what your letters are after your name. That helps us then begin to identify barriers. The important part, though, of the tool that that we've worked with through AANP is a resource tool on the back of the sort of conversation starters that has standards of care link. It's got the QR code. It's got overcoming inertia website that ADA has been working on, as you mentioned. But as prescribers, we have to be able to find the correct GLP that the insurance will cover. So there's some suggestions for formulary tools, coverage search, fingertip formulary. And if people access that through the AANP.org slash education link, they're able to go right to links that take them to a lot of these tools. So assessment tools are there as well. Diabetes distress, PHQ-2 and 9. Those are embedded in EMRs, of course, to a great degree. But referrals and then patient resources. As you pointed out, this is multifactorial. As Gretchen said, the patient may not be taking their medications. And certainly, Bill Polonsky has helped us identify over the last 10 or 15 years those primary issues. And while complexity and difficulty of the medications is part of the reason they're not taking their meds, it's also related to trust and cost and cultural things they bring into the visit. Hypoglycemia. So the strategy, I think, that's probably most critical is that we help our colleagues develop not just how to start the conversation, but how to be efficient with that 15 to 30 minutes. Make those referrals that are really going to then be able to address our limitation of time. Yeah, the progressive nature of the disease. That's a critical talking point and one that I know has been discussed quite a bit in this initiative and with all of our associations together. Gretchen, let's move over to you. What's a specific strategy or two that our audience could implement? So when I think about strategies, it really is based on what that patient's needs are and what their barriers are. So I think it's just really important that when we build a rapport with the patient, as Jonathan said earlier, just really getting to know the person, using motivational interviewing to find out why aren't they taking their medication and what would help them. With us, we do a few things, I think, that really helps with us in determining what's working for them and not and what they're willing to do. We do a lot of shared decision making. So we'll look at where they are. And the educator actually does this in the first two visits, parts of our visits before they get transferred to the nurse practitioner. But we'll look at where their sugars are at that time, what they're taking, and what could be a potential add-on or what would be a better medication. And we have cards written up for all the medication classes. And so we sit with people and we talk about the benefits and the risks of each one of the medications. And we also keep in mind the cost at all times. So we need to know, this is what the formula recovers and this is the price, so that we're able to assist that patient to find a medication that they can use. And the other thing that we're doing a lot now is the patient assistant programs. We have a lot of patients who can't afford their medication and especially patients with Medicare that don't have a secondary are already challenged. And so there are some really great assistant programs out there that have really filled the gap for those individuals and also for commercial insurances as well. Gretchen, a follow-up question from Catherine, where is the formulary link that you mentioned? Is there one in particular or Debbie, was it you? Sorry. So the link to those resources is aanp.org slash education. And then it's under tools and resources. And formulary link, formulary coverage search is my favorite. And I have it on my phone and use it all the time. Fingertip formulary is another one that's very popular. And our Epic EMR has a lot of that embedded. I find that not to be as accurate as coverage search. So I think you ought to experiment with a few of them, but you absolutely need something at your fingertip. Evidence-based guidelines tell us patients need a GOP if they're at risk, SGLT2 if they're at risk of cardiovascular disease. Well, that's everybody, but that's not enough. You have to, as Gretchen mentioned, find the one that is covered by that patient so that that cost can be bearable. Good point. Gretchen, a follow-up question also, patient assistant programs, any specific links or is that more community or regional? No, many of the manufacturers have them necessarily when you use the manufacturer names, but if you go to the ADA website, I believe most of them are listed there. They have a resource guide, but they also have something on, and I apologize, and maybe someone from ADA can look this up, but it is for people who cannot afford their insulin or having challenges with their insulin. And there's also information, I believe, on other medications. And many of the pharma companies are now covering support for up to 400% of poverty so people can make a family of two upwards to, what, $100,000? And many of the companies are now able to help during the coverage gap, that donut hole that our Medicare patients struggle with. So thank you, Gretchen, for highlighting that for us. And some programs are better than others. Some programs require the primary care to actually complete the application, and it really is a challenge for them because of time. So if there's any other support in your institution that could assist with that, that may help. Good, let's bring the pharmacists into the mix. So, Marianne, let's go over to you. Sure, yeah. I mean, the points that have been raised are just absolutely true. You know, adherence is an issue, transportation is an issue, the many social determinants of health, and just getting through the maze of insurance. And I am over 65, I had to sign up for Medicare, and I teach this stuff, and it was not easy. I'm gonna just say that. So that's a big issue. But to talk about that role, what I do for inertia, a lot of times that does come under the pharmacist purview if you're able to get a pharmacist in your, because those are the kind of things we learn in school, you know, is how does this whole medication use system run and where it goes and, you know, how to do it efficiently is a key. But, you know, it gets a lot more complex than that, I think, is where I know that I've come in as, when I'm working with such great team members, as we've talked about, dieticians and educators, and I'm gonna tell a story about it. I think what we think through, when I think through medication use and how a patient's using it, it just begins with, are they getting it? Well, it begins with, is it the right drug for them? Because it may be on a guideline, as Gretchen said, but, you know, there are all other meds that they're on, there are other conditions that they're on. It's looking at them comprehensively that affect that. You know, can they get it? Can they afford it? Is it working? And if it's not, why? Why is it not working? Is it something the patient's doing? Is it something unique to that patient? And then, you know, are they having complications and how can I manage that? And oftentimes that's where I, you know, I often communicate with our community pharmacists a lot, because there may be drug interactions you just cannot avoid. And you just need somebody watching them to see if it's going to happen. But my story is this very highly educated human resource gentleman who was on basal bolus, so maybe it's a little bit old now, but it's a great story, who had been through everyone, including the endocrinologist. And they just kind of went that, okay, we're going to send it to the pharmacist because she takes these very complex patients. And, you know, it kind of goes to trust, which was kind of interesting. And he had this very elaborate monitoring system that he had. He wrote what his sugar was before he ate, he wrote what he ate, he wrote, and I took my regular and I took this. And then I started looking at the, you know, the pharmacokinetics actually of the insulin that he was taking. And I said, this doesn't make sense when you say your sugars are this high and when it's this low. And as it turns out, then I finally asked him, when are you taking your regular insulin? And he said, well, after I eat, because if my sugar's 140 before I eat, that doesn't make sense. And he said, but when it's 300 after I eat, that makes sense. And he came in saying, I hate insulin because it makes me hungry and it's putting on weight. And, you know, and it really was thinking when I was looking at his sugars, I said, something is odd here. And as it turns out, he was taking it when it was 300 and he didn't understand the pharmacokinetics of the drug. So it's just an example of, you know, bringing all the minds together in a team and how it can work so well. Just a little bit of conversation can go a long way. Jonathan, your perspective on specific strategies. Yeah, thank you. So there's been a lot of great points raised so far. If I had to name one, I would just encourage, you know, the community pharmacists to set up an intentional time to talk about diabetes specifically with that patient. I think that's the best way to overcome therapeutic inertia. And I know the first thing a lot of community pharmacists are probably thinking right now is, I don't have time. I'm so busy. And it is hard to make that time. But you also can't assume that the patient has this team around them, that they're going to every single visit and they have a nurse practitioner on the team and a diabetes educator, and they're going to all of these things. That's not always the case in real life, unfortunately. So I would say, if you can, set up an intentional time to talk about diabetes specifically. A lot of pharmacies in the past couple of years, largely thanks to COVID, have kind of moved toward an appointment-based model. Granted, yes, primarily for vaccines, but there are other disease states that can be incorporated and are being incorporated in an appointment-based model, specifically for chronic care, such as for diabetes. So you can learn a lot in those appointments with the patient, whether it's scheduled, confirmed by email, a true scheduling appointment, or if you just say, hey, could you swing by after work and make 10 minutes of your time to come talk to me about your diabetes care? Show me how you're doing your finger stick, blood sugar checks. Let's talk about that and answer questions. I think that's extremely valuable. And then if I could just touch on one thing that's been mentioned a couple of times about the formulary. So that's brought up great point, Debbie, and Gretchen mentioned it as well, that certain things are covered or not covered. But I think what I was thinking of is, you know, it might be covered in November and then you change to a new year and it's no longer covered. And that's, it's frustrating for everyone. But unfortunately, you know, you might call the prescriber and they said, no, I checked the formulary. It was covered. And you said, it was, it was covered. And now it's not. Or for example, if the patient changed jobs and they changed insurances altogether, or the term covered is kind of vague. What does that mean? Is it tier one, a hundred percent covered? Or is it tier three, partially covered and you thought it was covered and it's still very expensive for that patient. Those are things that community pharmacists can help bring to the table and talk through with the prescriber. And I think that's our job is to help communicate with the prescribers about those items. Yeah, it sounds like that's one of the biggest challenges in diabetes care, Marianne. It's just something that popped in my head. I, you know, I think this team-based care and I've been doing it for a number of years is wonderful. But I also wanna, you know, we often look at the wonderful sign. I wanna share a back, you know, a downside. And that has to do with adequate communication and coordination. You know, sometimes, and I've had a patient walk in with the hospital, the doctor, the nurse, the pharmacist, the, you know, everyone giving him pieces of paper, a grocery bag full of pieces of paper and saying, I don't have time to read all this stuff. Just, you know, so I just want to caution and sometimes different messaging that wasn't very clear that as we work in as a team, the incredible thing, which is the value of huddles, whether virtually or, you know, is that we're all on the same page because it can be confusing to a patient and overwhelming. So I just wanted to balance that a little bit, that, you know, we think we're doing a great job, but we always have to look down the road a little bit and making sure we're not creating more harm. Yeah, no, thanks for mentioning that, Marianne. I also see we've got some great ideas and links from people in the chat. So just wanna highlight it for all of you who are here live. And for those of you who will be watching the archive, things such as NIDDKs, financial help with diabetes, getinsulin.org. Let's see, ADCES's Dana Tech is on here. So keep those ideas coming so we can share it with everybody who is a part of this webinar. All right, let's move on to our next question. What recommendations do you have for developing an inclusive care team to overcome therapeutic inertia? Oh, we've touched upon some of this, but, you know, what's that one or two thing that you would recommend? Why don't we start with you, Marianne? First, I'm gonna suggest collaborative practice agreements, at least for a pharmacist, because if you're going to wait for somebody to recommend something and somebody to read it and somebody to act on it, you've just created inertia. So I think that requires trust and confidence. And so you have to build that among the practitioners that I trust you, that you know what you're doing. And that is something that has to work on. But I think collaborative practice agreement is one of the critical things. The next is figure out your value proposition to have that team. It's tougher in fee-for-service, there's no doubt about it, but it's doable. And it works a lot better in a more advanced payment model where your team can figure out what are the needs of your population? And I read one last comment. I read a great comment that it matters less where you're at, where the practitioner's at. Are they in the clinic? Are they, but it matters whether you're providing the service your patient needs. And we should be focusing on that, and less so in like I'm in the hospital clinic or I'm in here is what does my patient need and who do I need on that team for them? Good advice. Let's move over to you, Gretchen. So I think it was you, Marianne, who said it. I just wanna echo communication. I think that is just so critical whether you're embedded in a team. So you may be in a primary care practice, an endocrine practice, or you may be in a practice like us working with our nurse practitioners and pharmacists and diabetes care and education specials where we can do medication management and move the people along. But many diabetes care and education specials are located in a variety of different locations. Inpatient, they may be an outpatient accredited or recognized program. And they're pretty much working isolated to themselves and not in a connected team. So I encourage everybody to think about the virtual team of working closely with the provider who's referring, but any other diabetes stakeholder, whether in the community, like the community pharmacists, anyone who can assist them. And I think it's a little more challenging when you're in an open system and people are referring from out and they're not in your EMR because communication oftentimes gets difficult. So we do need to have that trust with the primary care provider, open communication, find out what the best ways are to communicate with that provider. In the closed system, it's much easier to keep that communication going because in our system, in our EHR, we can message the provider and they have to answer that message. I believe it's within 24 hours. And so if we have any concerns about the referral, the patient, then we contact the provider. So they feel like they're constantly linked with us and they appreciate it because we provide them with valuable feedback. Gretchen, follow up question. Oh, go ahead, Debbie. No, I was just gonna say the portal we have to leverage as our time buster. That's got to be our friend. What about those, can you dive deeper into those people outside those clinicians outside the system? And do you have any tips on communication strategies to get that two-way or bi-directional communication? I'm just learning now. I work in a large healthcare system and we get most referrals from inside the system, but we do get them from outside and we're finding it the most challenging. And so for the people that are not in our EHR, we've just tried to find out what the best ways are to communicate with them. And then as we get more referrals from them, it's a little easier to communicate because the response was a little faster, but I really don't have any great tips right now. Maybe I'll come back at another time and share that. Yeah, okay, Debbie, go ahead. I think we're all like-minded and this kind of line of conversation is exactly what I wanted to kind of expand on. And in the open system, I think a phone call is critical. And you think, gosh, we don't have time to talk, to make a phone call. And, oh, by the way, you'll never get to talk to the doctor or the nurse practitioner. Well, so be it. If you can get the medical assistant and talk to them, you start the conversation with, I'm worried about blah, blah, blah, blah, blah. Because to Mary Ann's point, whoever sees the patient has to take action, regardless of the initials after your name. So you may be working with a referral from somebody and you wanna be sure they're on board with the prescription you're initiating. And so even if you get a voicemail and not even the medical assistant, that's when you do a two minute in-service and you can't go on and on and on, but you do a quick, short in-service. And that has at least conveyed that message that this is what's just critically needed and I'm going to go ahead and do that. I wanna be sure you're on board with this. If I've missed anything, here's my direct phone number. So I think the messages when we forward the after visit summary and those kinds of things have a two sentence opportunity as well, but nobody reads the AVS. The patient doesn't, the referring provider may or may not. So you have to speak in two sound bites, elevator talk to get your message across and whether it's voicemail or medical assistant, please share this with the provider. And then please call me back if there's anything I've missed or should do differently. I think that's critical for outside of your system, the open system. Yeah, Marianne, go ahead. I have one tip that amazed me how well it worked. And the system I was using then, not every system can do that, but it was Cerner system that allowed me to create a separate medication list that was out the after visit, that was as accurate as possible. And I put every provider practitioner that was on there with their phone number on that list. And I will tell you, I was amazed at how well, including my phone number, how well that worked because the patient, if it's close enough to what they're really taking and updated, it worked for us, but it worked amazing. We do not put enough time in the medication list with what should be in there, why something was stopped or why there, there's a lot that can go into that system. We have the technology, we're just not using it well enough. And the other thing is don't forget about SBAR. SBAR situation, the problem assessment and recommendation is a really quick way and to know how practitioner's office works. What I noticed is they're so busy during the day, at the end of the day, they have a stack, and if you can somehow send that information that either electronically or however it is, they will get through that stack usually before they go home. So those are the two tips I have. No, thanks, Marianne. Let's kick it over to the community pharmacist, Jonathan. Thank you. Yeah, so I thought Gretchen put it very nicely about communication. That's obviously key for any team. And then I think Marianne hit the nail on the head for pharmacists in terms of collaborative practice agreements. That's something that is very important to us. And that definitely allows the inclusive care team to develop. It's like that meta-analysis showed, which I think is in the chat or a link to it should be in the chat. Basically that empowering pharmacists to independently intensify treatment when necessary, obviously according to guidelines and protocol, really makes a huge difference. So yeah, I would just add on that really empowering the pharmacist is crucial. And then when pharmacists do come up with something that needs to be discussed with the entire team, one thing that's very important to us is that you're not only calling to talk about the problem, but you come prepared with a solution or a recommendation, a suggestion of a solution that saves everyone time. And you can just kind of cut that question out and just say, this is what I think might be something to consider for the team. And if that helps, I think that can really save a lot of time and it's just helpful to the entire team, so. Yeah, good tips there. Debbie, let's pass it over to you. Other tips, other strategies. Thank you. I've already kind of shared what I wanted to say, but let me add another thought that I had. We all want to work as a team and to win the hearts and alliance of those prescribers that we're all working with, I think we need to recognize their barriers. ACE has done a recent survey of both primary care and endocrinologists that identified time, as we've all addressed, cost and access for patients to get medications and services. So if we want to truly be helping a critical role in the team, we have to help address those three issues. We all do time very well with, we do education or med reviews and education around the meds, but access I think can be facilitated, not just by sharing formulary search tools, but by taking that extra step of identifying what's the medication. The best practice for me in a brief time is to, after talking to the patient, having shared decision making about the med, I'll go ahead and send the script for that to the pharmacy, then continue the visit with the foot exam or education, call the pharmacy after a few minutes, beg them to run the script and see if it was the formulary preference and what is the out-of-pocket cost. Because the patient who goes to the pharmacy and they say it's $400, well, obviously we picked the wrong GLP or SGLT-2, but to the patient, they're done. So if we can do all of that in a brief amount of time during the visit, we've facilitated that adherence, we have moved past that inertia that then goes on for several weeks because we picked the wrong drug. So we as providers, as nurse practitioners may not be able to do that, but the medical assistant may be able to follow up on that in the office. But that needs to happen in my view before the patient leaves. And if you pick the wrong drug, the pharmacists are brilliant and they will sometimes say, this is the one that's on formulary if you haven't been able to sort that out. So become best friends and beg for help to do that so your patients are on board. Of course, providing samples helps as well, but they've got to know what's my cost, can I do this? Great tip, Debbie. And it seems like we've got lots of questions in the chat. If you have other questions for the panel, pop them in there. We'll see how many we can get through. Reimbursement costs, formularies, this seems to be like a big old theme in the chat as you can all see. Gretchen, go ahead. Now, I was just gonna say, it looks like somebody answered the question, can you bill for DSMA? And you can bill for it, but you do need to be part of an accredited or recognized program. And so if you're not part of one of those programs, please contact, go to ADA.org or the ADCS website to learn more about how you can actually become accredited or recognized so that you can bill for these services. Yeah, thanks for answering that one. How about when you have both CDCES and ambulatory pharmacists in the clinic, how do you envision that they can work together to best care for these patients as much as the work overlaps? Does anybody wanna take that question? Yeah, I will because I worked with them. And it was really focusing on medications and what was the highest problem for the patient at the time if it was the diet. So we all knew what we were all saying and reinforced it. And if you look at education, that's a good thing. But my focus was more on the medications. Are you taking it? Is it the right one? Is it working? What are problems you have? Are you fitting it in? What's the adherence problems you're having? And then of course diet would come in there or other things would come in there and then vice versa. And we're the dietician, the diabetic educator that I worked with, and we just talked. And they heard it three times. And I don't know about the condition of your population, but I learned that just to get them to know what their blood sugar should be and what to do if it's high or low with their fasting blood sugar, sometimes took three visits. It reminded me of grade school where you jumped up the reading escalation. Sometimes we just boom them and what do they remember? And so it really had to do with a focus and the focus varied over time based on what the issue was with that patient. Was it more a medication issue? Was it more a dietary issue? Was it more a physical therapy with exercise? And what were we seeing when they start exercising and how we had to decrease the medication then? I mean, you just had to communicate and be a team. Yeah, Gretchen, go ahead. No, I was just gonna make the comment. It didn't have to do with working together, and it does. We find as diabetes care and education specialists that a lot of our patients really do not know what they're taking, why they're taking it, how it works. And so I think that's the critical part of working with our pharmacist colleagues and our nurse colleagues, and that we all need to, it's not just one person. I tell our registered dietitians, you may be the only person that they ever see. They may not see a pharmacist or a nurse, so you need to talk to them about the medications at that visit. So it's just, I think it's important that we support each other and just keep on, like you said, Maryann, you have to say it three times, but it's overwhelming for many people. They have many other things going on in their life other than diabetes. Yeah, oh, go ahead, Debbie. I was just gonna say it's helpful, I think, for patients to kind of see what you think the long-term plan is, not just this is the medication you're taking right now. Here's how it works, here's when you take it, here's the side effects. People need to know diabetes changes over time. And if we're staying current with the guidelines, we are recommending a combination medication. We're recommending much more than metformin right out of the gate, and using the SGLTT and the GLP together, metformin plus or minus. This is so different than what we've done for decades. Patients need to know that if I'm queen of the world, I want them on all of those medications, metformin if they can, but the GLP, the SGLT2, whatever else, insulin, somewhere down the road may be needed. And people need that long-term view as well. Here's what you're doing now, here's what may be on the horizon, and you haven't done anything wrong. Right, insulin does not mean that you are a failure. It's a progressive nature of the disease. Yeah, very good point. We have a question about the donut hole. Debbie, I believe you brought this up, but we'll throw this out there to any of you. Can you elaborate on the financial help during the Medicare donut hole? Are pharma companies allowed to provide discounts to Medicare participants? Any comments on that? Yes, some of the pharma companies are doing that. Now, Marianne's shaking her head yes. Maybe she wants to jump in here as well. The challenge here, some are, some don't. Some have different rules, they have different forms. It is work, but sometimes you have to change the drug to find the one that will cover it during the donut hole. So, what I think is you need a highly trained technical person to do that. And I've worked with LPNs doing that, and I've worked with pharmacy technicians doing that. I mean, I think you just really need somebody to work with that. And then you help them with the filling out those sections of rationale. But it's not an easy thing, but if you try, it's there. The other thing is it changes. Just as formulary changes, policies change. So, you're gonna have a company that will do it, and then next year they don't. It's a challenge. It's not uniform or standard, which is, but they do. I mean, the answer is they do, it's just. And some of them have started verifying financial qualifications over the phone. So, that inspires people to do that paperwork that may be required. So, while it is very different with the companies, they are much more generous than I think ever before. Insulin availability, insulin affordability is much more generous than it has been in the past. And I think that is something we need to leverage with all of our patients. They can get recombinant DNA human insulin at Walmart for $25 a vial. So, we don't want people to go without their medications. A great comment from Alicia in the chat is about the behavioral medicine side of this. Fear of needles or injections. Does anybody wanna talk about maybe how the behavioral medicine part of this plays in the whole care team? Oh my gosh. Well, I'll chime in briefly and then defer to others, but this is a great topic that we have to address very briefly. But yeah, so I think that is true. A lot of patients do have a fear of needles. However, there's also, I think sometimes assumptions that there's fear of needles or I think just a misunderstanding. I know I've had patients that kind of has shown hesitancy towards some needles, but then I give you your flu shot every year and you have no problem. And so it's really, I think it's an education piece that it's not this huge needle. It might just be a very small needle and they just simply don't understand. They hear the word needle injection and perhaps there is a true phobia, but to the point of the question here, I do think with education that those fears can be overcome. I think the other thing is persistence, is an acknowledgement that this is real, this is true, but don't give up. And I think giving up is a lot of reason for inertia. And I distinctly remember one patient who was fearful of needles. And I talked about how thin it was. It's like, it's not even as bad as a paper cut, that hurts worse and going on and on and talking about different areas. But part of it was building trust with me until she finally relented. And then she was so much better controlled. She said, I should have done this three months ago. But that then transfers to the next person or to whoever she's talking in the waiting room. So I think persistence is a key, is just don't give up, be positive and do not give up on a patient. It's a good message, Mary Ann. Debbie. I agree with comments from Linda and Alicia. The diabetes educator is the expert at this. And it's so important that we help people get over that hurdle. One of the tips I do, I used to have everybody take a bottle of saline and a syringe and self-inject. I do that some if I'm on a one-on-one visit, but in group class, I will pass around a syringe that we used to use with the half-inch needle. And then I'll put a new pin needle on a saline demo pin. That's the four millimeter pin needle. And I'll pass that around. And it's interesting to watch people's face when they take a hold of that syringe or they take a hold of that pin and they're looking at both of them. And it's like, oh, oh my gosh, that desensitization helps them be one step closer to taking action. But I can tell you, this can be done virtually as well. During COVID, I've helped people start insulin and start GOP virtually. So it can be done and we have to stay right there with it, be positive and supportive and help people just do it. Yeah. Well, I'm afraid we're going to have to end there. This has been a fabulous conversation. I think a lot of nuggets of great information and advice from our panelists. Thanks so much to all of you for your time and for your expertise. We want to thank again, our partners in the Overcoming Therapeutic Inertia Initiative, AANP, ADCES, the American Pharmacists Association, the American Society of Health System Pharmacists for your work on building and disseminating all these great resources. We also want to thank our supporters, AstraZeneca, Sanofi, Merck and Novo Nordisk. Please visit therapeuticinertia.diabetes.org for specific resources that were mentioned in today's talk. And I wish you all a very pleasant day. Thanks so much. ♪♪

Overcoming Therapeutic Inertia

Diabetes care

Team-based approach

Collaborative practice agreements

Medication access

Patient fears

Financial assistance programs

Persistence

Empathy