Hello and welcome to the ADA-sponsored interest group entitled, PharmDs to CDCES, the Bridge Between Endocrinology and Primary Care. My name is Paige Johnson. I will be your moderator. These are our objectives. We want to hear from you, and especially for this presentation. We tried something a little different. We would love your feedback. There will be a brief survey in the chat box at the end. The presentation will be short but informative, followed by a roundtable discussion. Our panelists will break the ice with a targeted Q&A that really aligns with the objectives to make sure they're met. Please feel free at any time to join in and ask questions. I'm going to pass it on to Ms. Christina. Awesome. Thank you, Paige. As mentioned, my name is Christina Knotsman. I am a pharmacist program coordinator at the Barnes-Staples Brown Diabetes Center with the University of Kentucky Healthcare in Lexington, Kentucky. I'm just going to start us off talking a little bit about the role of the CDCES and who CDCESs are just as a kind of foundation for our conversation today. As you can see by the diagram that's on the left of the slide, the CDCES community is a really diverse community with healthcare professionals from all different backgrounds. That's a really unique and I think applicable part of being a CDCES is we have a lot of people who have a lot of different perspectives in healthcare that really can help support people with diabetes. If you're not familiar with the requirements, I have them listed, but definitely check out the Certification Board for Diabetes Care and Education if this is something that you're interested in learning more about. But not only do we have a diverse background of people, so people who are physicians, providers, nurses, dieticians, pharmacists, social workers, and more, we also work in a lot of different practice settings. I think most people think of CDCES as working in an outpatient clinic, but many times they're also working in hospitals, both in specialty clinics as well as primary care, in public health arenas, also in other specialties like podiatry or ophthalmology. So just a lot of different places where CDCESs really touch people with diabetes and help support them through their care. This is a great diagram that comes from a consensus statement on the role of the CDCES and really identifies four critical times that we want to be partnering with CDCES as for our care for people with diabetes. I think most people think of at diagnosis, that's kind of the one that everyone thinks, oh yes, we need education at that time, but there's really other times that are very important as well. So just when patients are not meeting the targets that they want to meet for their diabetes, even annual check-ins sometimes are good just to make sure that we're hitting all those core concepts. When complications develop, that's also a really good time to kind of check in with a diabetes educator. And then when transitions of life or transitions of care occur, so whether it's after a hospital admission or maybe it's moving from the pediatric clinic to the adult clinic, there's a lot of different transition times that can be hard to navigate for people with diabetes. And then my co-presenters are going to talk a little bit more about this in a minute, and we'll certainly highlight this in our discussion, but these are just some of the benefits of diabetes self-management education and support that have been documented through various studies. And I think many of us think of those good clinical factors, so things like A1C improvement and decreasing hypoglycemia, but there's also a lot of quality of life that is supported by participating in DSMES. So things like improving quality of life, helping with healthy coping, enhancing that self-efficacy and empowerment. So just wanted to include these, really thinking about holistically the care that the patient receives with the CDCS. For our next little bit of discussion, I'm going to pass it off to my colleague, Liz. Clotis, you're on mute. My apologies. My name is Clotis Johnstone. I'm a PA and CDCES at University of Kentucky Barnes-Stable Brown Diabetes Center, where I'm lucky to get to practice with a PharmD CDCES, Christina, who we just spoke with. We've gotten to work both in the inpatient setting and outpatient setting together and really have seen firsthand the benefits of diabetes education and bridging the gap in many aspects of care. And as we think about DSMES, really, it does serve as a communication bridge between the patient, the educator, and the provider for the patient, whether that be a primary care provider or an endocrinologist. So in 2022, the ADA updated their standards of care for DSMES, and Standard 5 is about patient-centered DSMES. So the requirement is that the DSMES team will monitor and communicate the outcomes of DSMES services to the diabetes care team and the referring physician or other qualified health professional. So if you look at this great graphic, you kind of see the patient right here, because we're always thinking about patient-centered care for people living with diabetes. And you start with a referral from the participant's provider. Obviously, it has to fall under their insurance requirements. And you have the whole comprehensive diabetes education cycle, where we're thinking about things like problem solving, reducing risk, monitoring, taking the medications, those ACDS behaviors we're all familiar with, being active, healthy eating, healthy coping. And the outcomes of that assessment and that coaching provided by the diabetes educator is communicated back to the referring provider, again, whether that be a PCP or an endocrinologist. And where we really see this benefit, this working group is about diabetes technology. So if this patient needs to be started on a sensor, we can use that CGM as a point-of-care way for a patient to look at their glucose if they're doing it on their own. But if you incorporate the diabetes educator in there, you really get them to be an advanced user where they're problem solving. What made my blood sugar go up when they look at that? What is my time and range? How can I use that to improve my care or reduce my risk? And those patient skills can be referred back to the provider and communicated to them as part of that DSMES cycle. So when you think about initiating a referral to DSMES, there is an accreditation and recognition process, for those of you guys aren't familiar with DSMES. And it basically ensures that there is quality associated with the education provided by diabetes educators. Programs that are accredited either through the ADA or the ACDS meet these quality standards and it makes them eligible for billing. Those referrals are in compliance with Medicare requirements. But both the ACDS and the ADA have great search engines for providers who may be in rural areas and don't know where the nearest qualified diabetes educator is. So over on the left, you can see the ACDS. Once you've put in a zip code or a state, you can find a map with the closest places. So that's the Kentucky map. And you can see we've got folks in Lexington and from Eastern Kentucky and Western Kentucky. The ADA has a very similar tool and you can see the initial part of that when you would type in your zip code. Later on today, we're going to talk a little bit more about communicating with providers as a diabetes educator to kind of advertise your program and make sure you're visible. And finally, kind of getting back to this theme of bridging the gap. The communication back to the referring provider is a huge part of the standards of DSMES. So standard five is about person-centered DSMES and the final qualification for that is communication back to the referring provider. So for every referral, the diabetes educator needs to communicate that back to the provider. We hope to facilitate that through EMR, so ideally you're getting those records via the EMR. Some practices that aren't EMR-linked, we're still sending paper letters notifying them or faxing them what's happened. So it should contain a record of what happened in the DSMES session, talk about the progress of the patient, the outcomes, and a follow-up plan. So it may even say, hey, we'd love to see your patient back in six months, or if there is a change in life circumstances, we may need to see your patient again. And really that communication, it serves as keeping the healthcare team on track together, but it also is thought to reduce therapeutic inertia because it can really help the provider prompt their patient on knowing what all they've learned and what their goals are. And from here, I will let Kathy take it over. Hi, I'm Kathy Jackson. I'm RN coordinator of Atrium Health Union and Atrium Health Union West. We're located in the Charlotte region. We are an inpatient and outpatient diabetes center. And the sad reality is that our services, although very valuable, especially in assisting patients change their behaviors, not very many patients actually see us. And so only 5% of Medicare beneficiaries with newly diagnosed diabetes use DSME services and 6.8% newly diagnosed type 2 diabetes with private health insurance received DSMES within 12 months of diagnosis. Recently, someone shared a case with me of a gentleman in his 30s who was diagnosed with type 1 diabetes, and he was 30 years old when he was diagnosed. He never saw an educator. He came back at 38 having all kinds of complications, lots of low blood sugars and never got the education he needed in how to treat low blood sugars, how to prevent low blood sugars, and also how to prevent complications. And so at 38 years old, he's he's dealing with retinopathy and some other things that are tragic. And so, you know, we can help teach the patient all those lifestyle things that that are just very beneficial for somebody to live well. The goal is to live well with diabetes. And, you know, as far as diabetes education does reduce A1C, I know that's something that a lot of physicians, they have their parameters that they need to meet for A1C goals. And our center in 2022, we reduced our average was 1.5 percent. And then I looked up a recent report from the American Family Physician, February 15th, 2018, and the reduction was 0.34 to 1.8 for education. And all those are statistically relevant. And so, you know, it helps with the medication, but also with the education and behavior change. So why use one? And it's because really what Clovis and Christina actually have been sharing is we get into the daily life of living with diabetes. We are we are coach. We don't just say do this, do that and just give them facts. You know, we're not like they can get on the Internet and they can learn facts. And some of it's not true, but, you know, they can they can learn on their own. But we help them get some nitty gritty and discuss behaviors and how they can change and, you know, and ideas of what they can do with their culture and with their family situation. An interesting thing is estimated with medications. We go over medications, you know, half of the people who are in regular medication do not take the proper doses at the proper time. And I can't tell you how many people I have talked about not taking clopazide at 10 p.m. at night. You know, no wonder you're having lows in the middle of the night. But so these are and some of them say I've had diabetes for years, but they don't know what they don't know. And and even with the medications and sometimes doctors, they don't want to tell you they don't want to tell you that they're not taking their medication. So they don't. So what do you do? You just keep increasing their insulin or whatever. And the truth of the matter is they don't take it very often. We try to get into that and and tell them how very important it is for them to be honest with you. I can't tell you how many patients we've had in the hospital. They put on their same insulin doses that they're taking at home and they start to have a lot of lows in the hospital. That's because they don't need those insulin doses. But the PCP is unaware of that diet. We don't concentrate just on restrictions, but how to make small changes at a time that will eventually have great impact. So we make small goals with the patient that they build upon each goal. And again, we look at their habits, their culture, their family. We assist them in making healthier choices. And we put the the control up to them. They they choose what area they want to work on. And that's what that's really important. If they're really going to make a change, they have to take ownership and decide what goals they want to work on. And we help them with that. We also assist patients in making a movement plan. We talk about exercise, but some people really have a difficulty with exercise. So we, you know, we start small and build up to it monitoring. So we help patients use the data from finger sticks or CGMs, as already been previously mentioned, to figure out how their body is responding to food and drink and exercise. So we kind of dig in with them and their habits to determine why they're going low. And sometimes they're going low because they're not eating properly or they're they're not adjusting for exercise and those kind of things. And we dig into that with them. CGMs, we really look a lot at with them of how to how it impacts their time and range. And and then we also help the CGMs also help the doctor. You all your PCPs determine what medications should be considered. You know, is the issue with the patient, is it with their fasting or with their postprandial? You know, I've had people tell me, I don't understand why my A1C is so high. My blood sugar is always fine, but they're only checking it at fasting. So they never know what is doing postprandial. They have no idea. And somebody can have a great A1C, but they're having a lot of lows and a lot of highs. So the CGMs really are a great tool. And just for you guys to know, Medicare will pay for a professional CGM. So there's two different types of CGMs you can order, a professional one and a personal one. So the professional one we put on at the clinic and they wear it for two weeks and they come back and we download it two weeks or 10 days, depending which one we get. And we download it and go over all these things with the patient. And Medicare will pay for one once a month, pay for a professional one. Medicare will pay for a personal one, but they have to be on insulin. And so but they can get a professional one. But there are differences. If the patient wants to have a personal one and their insurance covers it, that's great. They really they will really learn a lot from that and make their own lifestyle changes in between visits. They'll be able to see and make their own decisions easily. But it's important that also that they get trained in in using a personal one, have them come to an educator because we know the ins and outs of those and we teach them. What do you do if the arrows are going straight up and going straight down and those kind of things? So we go over that with the patient so they really have a good understanding so they can be successful with it. And the importance of a primary care provider, most patients with diabetes, they don't see an endocrinologist. And there's a shortage of endocrinologists. I know that when the endocrinologist I work with, she's got a three to four month wait. And she's actually that's pretty good. She told me. So, you know, our goal is actually try to help the patient never need an endocrinologist. You know, let's let's work on those behavior changes that they can do so they don't have to be referred to an endocrinologist. So hopefully they don't become uncontrolled. And we we assist the PCP by by working on the many difficult lifestyle changes they need to make. But again, you know, it's a step by step approach with them. And recently, so we made a video with one of our family practice medicines to show patients what we really do. You know, so they understand that we're not just giving them do's and don'ts. We're not just telling them what to do. We are involving them in all the decision making and that we're more of a coach. And so we made we made a video. It actually made about three years ago. But COVID hit and we have not implemented all this. And we're actually in the process of implementing it. And we've made this video. We're going to put it on our brochures. We're going to give it to our family medicine. Our internists are endocrinologists to give to their patients so the patients can view the video and see what we really do. And I know the doctors who have seen it, they love it and they they think it'll go over well. So hopefully this will bring more patients who are wanting to have to come for education and coaching. And I will pass this back to Paige. Thank you, ladies. We are now going to begin our roundtable discussion. We'll break the ice with some questions since I don't see anything yet in the Q&A. So I have had a great time working with these ladies. They are very, very intelligent ladies. They've had a lot of different experiences. So I want to start with Christina. She has actually her and Clotas are our partners as far as in the diabetes world where they work. And they have worked in an inpatient facility. And I'm very interested in hearing from you, Christina and Clotas. How do you how did you like the inpatient and exactly how did you get there? That's a great question. I feel like Clotas and I have been working together for about five years now. When I started with my position, I was split between inpatient and outpatient as a pharmacist. It was a new role trying to work with endocrinology to support people with diabetes that were taking care of at our diabetes center. And Clotas at the time was an inpatient PA on our inpatient diabetes team. So we worked together a lot on the inpatient and she also took care of outpatients. So I'll let her speak a little bit more about her role. But I think we both feel really passionate about transitions of care and continuity of care and making sure that we're supporting people with diabetes while they're in the hospital, not just giving them the right dose of insulin, but preparing them to then manage their diabetes as they leave the hospital independently and also supporting them through that. And so as both of our roles have kind of evolved into different things, and I now exclusively practice outpatient because we were able to add a pharmacist exclusively dedicated to inpatient in what I was doing before. Clotas and I have really gotten to work together on thinking more about that whole process, including education and management for patient care, especially in the transitions of care role. And to echo what Christina said, our practice managing patients with diabetes, unfortunately at UK has grown, we'd like to see more prevention. But those patients we do have who are living with diabetes, like Kathy said, we want to make sure they're living with it and living well. My role at UK, I originally started practicing as a PA in primary care, but came into the endocrinology world, really filling a gap for our inpatient services and really focusing on placemic control in the inpatient setting, but had the opportunity to do a continuity clinic for myself where I would follow up my patients in the outpatient setting. One of the ways I became interested in diabetes education, our outpatient world had diabetes educators at the time and they really supported me in clinic as a clinician, I had back to back appointments, but my educators were really able in clinic to spend the time teaching my patients the self care behaviors that I was recommending and kind of tailor them to their lifestyles. We also have a freestanding education center where I could refer people for formal DSMES, and I really saw the benefit of that for the patients because it was taking the advice of the provider and tailoring it to the goals of the patient and the lifestyle of the patient. Things as simple as, you know, you might not think as a provider, but sort of physical disability might prevent somebody from using a syringe, but maybe your educator has a little more time in the room with them and notices they have a tremor and may come out to you and say, hey, could we PA a pen for this patient? Even though it's not in their regular insurance formulary. So I became interested in the role of the educator and actually pursued a CDC, yes, because I didn't have that support in the inpatient setting, really believed in kind of that holistic model of care where we're really meeting all the needs of our patients. There's a really good question in the Q and A that I know in your experience, you are in charge of reaching out to the different primary cares in your area. And I'm assuming that you have some rule primary care providers. And one of the questions is there are so many small practices that cannot afford to have the supporting staff, any suggestions for those practices? Absolutely, so one of the things we definitely recommend is looking to areas with federally qualified health centers. A lot of federally qualified health centers will do sliding scale for patients. And so let's say you're a primary care in a rural area and you have a cash paying patient, many federally qualified health centers have pharmacists, dieticians, some of them are CDCSs who can see your patients and they'll see them on a sliding scale. And I think they would to meet that standard of communicating that education back to you. They may even be able to get that patient medications or technology for a reduced cost on that same sliding scale. And I think Christina could speak to that herself as she did practice originally in a federally qualified health center. Yeah, I think we've talked about this a little bit as we prepared for this webinar, but I now work within technology and we have a really large group, diverse group of diabetes educators, which is really fun because everybody gets to kind of practice to their expertise in their role. But my previous role was at an FQHC. I was the only diabetes educator and I kind of did all of the things, but I saw it being a diabetes educator because that's a lot of what I was taking care of were people with diabetes and I really wanted to grow and kind of make sure I was supporting that role appropriately. I think identifying people on your team, even if it's a small team that have an interest in diabetes and supporting them in pursuing that CDC certification or working towards it can be really impactful. Many people in healthcare are either personally affected or have family members affected by diabetes and feel pretty passionate about that population. So that would be the other thing I would encourage small practices. I'm a pharmacist. There's a lot of community pharmacists or pharmacists that work in maybe non-traditional settings that have a really big interest in diabetes for a variety of reasons. So kind of thinking through who is in your community and kind of has an interest in caring for this population. Like Cletus mentioned earlier, I think it was her. You know, you can always go to the ADA and enter your zip code and find a diabetes educator if there's one within a certain amount of miles in your area. There's another good question. Are there rules or regulations around CDCES professionals making insulin dose or insulin pump adjustments for unsupervised by a licensed prescribing provider? Actually saw that question pop up in the chat. I'd be curious to see how everyone else handles it. So in a lot of circumstances, I think that most, you know, for our educators who are at our center, who are making any sort of insulin dose adjustment or pump adjustment that follows under a standardized operating procedure that we have written out, they're within the bounds and then our physicians or APPs sign off on those. I think for the most part, you know, when we think about referring, if a primary care is to refer to a CDCES, I don't think the intention of that CDCES is ever really to take over medication management. Now that CDCES may communicate if it's Kathy and I've sent my patient over there and she had more than the 15 minutes I had with them and she finds out, hey, Clotas is increasing the basal, but your patient is only taking that basal two or three times a week. You know, it's the actual behavior, not the medication that needs adjustment. She may communicate that to me and suggest to me as a provider. And, you know, similarly, I think that works that way with other healthcare providers. I've had physical therapists where I've sent my patients to cardiac rehab, say, hey, you know, this is going on, what do you think about this medication adjustment? But I think generally CDCES is, unless they're working closely with a provider under a standardized operating procedure, I think they're really more doing the digging and helping that provider make the changes they feel is appropriate. So we have to operate within our scope of practice. And as an RN, I can't do any prescribing or adjusting unless I have an order from the provider. Same with our dieticians. You know, so Clotas and Christina have different roles because they are providers and pharmacists, but those of us who aren't, we have to go with our scope of practice. And I want to, I don't want to make those decisions. That's not up to me. In our office, we have a protocol that was approved by our providers. Actually, it went through multiple departments and we have, we can make adjustments within that protocol, but beyond that, we would have to get an order from the provider. I don't think that really attests to that team model of practice. You know, Kathy may have time or Paige may have time to dig up something that the primary care doctor didn't in that medication treatment, or maybe the patient asked them about a GLP one, and that's something they would communicate back in their note and say, you know, this patient has expressed this interest, but I don't think anybody is actually as in their CDS role solely based on their primary licensures, unless it's allowed, they're not writing a new medication. I know in our office, a lot of times I will see a patient, you know, sometimes, and like you mentioned, we have a little bit more time with them. And for, I think Kathy alluded to this earlier, sometimes they tell us stuff that they're not going to tell their doctor. And so when we just like get real honest and say, you know, there's no wrong answers in the room, this is what I need, you know, this is what we need to know. We're just trying to help you, keep you safe. And usually those things, if it tends to direct us in a different direction, a lot of times I will convey that in, we call it an EPICA in-basket, and actually contact the provider directly and say, you know, this is what I kind of uncovered in our encounter, and I was just curious, what you think about this, and maybe what do you think would be a good approach here? A lot of our primary care providers and one of the primary care offices that I actually work in once a week, we've all kind of started using the ADA standard of care mobile app. So it's kind of really neat to get in a nice conversation about that and really get to know the people and have a conversation about that. And in this primary care, we have residents and fellows and attendings, because it's a big office for Medicare and Medicaid in our system, so, and under uninsured patients. And so that's kind of been our standard there to kind of direct us in what to do. So we communicate about those things quite often. Christina, what does the role of the CDCS in optimizing diabetes technology in your institution specifically look like as far as, do you have programs that try to incorporate it into the primary care offices or? Yeah, that's a great, I think that's been a really fun thing for us to kind of partner with over the last couple of years. And I'll let Clotas chime in too, because once again, we work together and she has a big role in this, but as we've seen really great CGM coverage here in the state of Kentucky the last few years, it's no longer just endocrinology, right? Prescribing diabetes technology, especially continuous glucose monitors. But a lot of times our primary care colleagues don't have as much education or training on diabetes technology. And so they really have kind of let us partner with them more on providing education to the patients, but also helping them figure out like, how do we include downloads into our workflow and evaluate those? And how do we troubleshoot all the technology problems that inevitably come up? Our diabetes education center has several technology classes that patients can take. So whether it's a CGM education class with a new CGM start or someone who's having issues with their CGM, and then obviously doing like pump assessments and pump trainings is a huge part of technology as well. Clotas, I'll let you add in anything that I missed there. Yeah, I think that's a huge part of it. I think we have had the great opportunity to use CGM in so many of our patients based on coverage and for primary care providers who may not be as familiar, it's a great opportunity for them. Maybe traditionally, they might have sent somebody who needed a technology related to diabetes to an endocrinologist if they weren't familiar with it, but really they can, to use the name of the webinar, bridge that gap by getting the patient signed up for a DSMES related to diabetes technology and getting that patient on the sensor. And I think sometimes the patient comes out of that opportunity really knowing more about the sensor than their own primary care provider and really gets to teach their provider, but it may prevent a trip to an endocrinologist. And as Kathy alluded to, a lot of endocrinologists are stretched for appointments. Maybe it's an access issue for the patient. Somebody mentioned rural areas or areas that are far away from major medical centers that may not have endocrinologists. So it can really keep patients in their primary care home if we teach them how to utilize that technology. Some of our patients are fantastic and you can train them to get their own downloads and take it to their provider, or even just teach them how on their phone to show them, this is what my time and range has been. This is what my numbers have been looking like. So education is a great opportunity. And I agree with Christina. We've also worked in looking at flows for diabetes technology in primary care offices, professional CGMs like Kathy spoke about. I think that's a great opportunity for primary care to incorporate that into their practice. One of the primary care practice that I provide diabetes education once a week for, when I first took that position, there was a lot of therapeutic inertia around hypoglycemia and basal bolus insulin. A lot of their patients actually was still on the mixed insulin twice a day. So one of the kind of things that I sat down with the medical director and talked about, we talked about different ways to lower their A1Cs and we talked about maybe a basal bolus regime. And so I kind of asked her, I said, how involved do you want to be as far as do you want your clinic to be? Do you just wanna refer all your patients to the diabetes educator and let them start the train the device and bring them back, get a download and just kind of that's, get them started and that's it. She actually wanted the full court press, if you will. She actually wanted to identify a diabetes champion in her office that I could train, that could learn how to apply these devices to actually download them in the clinic with her patients. And she found it so fascinating when a lot of her patients were placed on CGMs, how much more interactive they were in their visits. One of her favorite patients had bilateral amputations and he couldn't read. So we chose a CGM that was really good for him and he would never consider changing any of his insulin doses because his child, his daughter had passed away in his house from a hypoglycemic event. This was before CGM and she ordered a CGM. We trained him on it. It was all about colors and numbers and arrows, which he picked up on very quickly. Now they have the best visits. He brings his reader. He has already can engage in a conversation and talk to her about what his sugars are doing and how he feels about it. And it's just been a big thing for that patient and that provider. And in that particular practice, once we started integrating the CGM technology, now you have the PharmDs there that are doing trainings and you have two PAs that actually, once we train the CGM, follow up, get the download, send it to the provider and they make changes if necessary, we actually put them in a couple of different titration clinics so that two of the PAs run in that primary care two afternoons a week and they love it. So it's actually different ways that you can play that out depending on how involved you wanna be. There's one primary care provider that refers to our clinic and he just wants the basics. And he just wanted to contact information from industry. He had her come and explain things for him, set up a portal and he does his own thing. So there's a lot of different ways you can do it depending on how involved you wanna be. And there's also nice, and Clotis, you can speak to this. Do you do, do you charge for the interpretations on a CGM report if a colleague, like a CDC is, downloads a Dexcom and sends you an interpretation? Will you charge for an interpretation code there? So at this time, our office is charging for the interpretation of the CGM in office. So if a patient has an actual clinical visit, we are not doing it. If a question comes in and that CDCES, maybe they're triaging something and they ask us a question, we're not charging at this time. But there is a lot of billable opportunities and I'll say both the ADA and the ACDES has a lot of information on how to do some of that remote billing. And you can bill based on time, the actual interpretation, the length of the wear in the case of a professional CGM. I think there is a whole lot of opportunity. And I think just as much as the billing, which is really important, I think it's just great care for those patients. Why do you think diabetes education is so underutilized? I'll answer that because I'm unmuted. Oh, Kathy came on. I think the patients often have that mentality. One access, distance, time are all great reasons. I think patients are often, well, I've had this disease state for a while, I know a lot. And I always encourage my patients and tell them, I still learn every single day from my patients, from reading journals, from attending conferences about how to best manage diabetes. I've spent my entire career, that's what I do all the time. I think that you too could benefit from meeting from somebody. And as Kathy said, I'll often tell them, it's both education and it's coaching. Kathy, I'll let you chat. What do you think are some of those barriers? Well, I think it's one barrier is that people don't know that we exist, that there are diabetes care and education specialists. We used to be called just diabetes educators, but that wasn't quite what we really do. It's more than that and coaches. And I also think providers don't know that we exist. And I'm glad that Clodagh shared how to find an educator that is in a zip code for you. And also a lack of understanding of what it's gonna cost. And Medicare, Medicaid actually pay very well for our services. Patients don't end up eating that cost. We don't get paid very well, but the patient doesn't end up having to supplement the costs. And most insurances will cover some portions. We're finding some that don't cover well, but it's something that the patient can investigate or we will investigate for them what their coverage is. And so I think that could be a barrier. And just a lack of understanding what we do. You know, if someone says, okay, I'm going to refer you for education, that may sound boring to them. Like they're going to be sitting, sitting and just, you know, again, being told do's and don'ts and, and they've had it for a while and just not understanding that really it's more coaching and encouraging and, and giving the controls back to the patient. I'm going to chime in on this one too. I think one of the reasons it's underutilized is we don't offer it enough, right? Like I think many times there's a lot of ways in conversation. I'll give an example. I saw this patient a few weeks ago. She was very endearing, had made a lot of lifestyle changes and told me that she had been watching a lot of Tik TOK videos. And this is where she was learning about how to eat better. Now that she was on Mungero and like trying to get her diabetes under control. And so then we opened the door. I'm like, okay, that's great that you're seeking this education, but what if I set you up with an expert, right? Like, can you, do you want to talk to an expert about these lifestyle changes that you can use to really help tweak your behaviors and all of these things in your life that you're doing to try to better manage your, your blood glucose? So I think that sometimes it's just finding, we have many patients that come in and say, I'm trying to work on my diet. I'm trying to be better about taking my insulin. I'm trying to do this better for my diabetes. And those are great opportunities to say, let us help you a little bit with that. Since your system, I know your system has some different models that you provide DMS and MS2 as far as primary care providers. Can you, can you share with everyone how your system, you have two different ones in your system. Can you share how both of those are, are managed and kind of how they work? So we have educators who operate hospital-based and they do inpatient and outpatient education. So some of our hospitals have that. Some of our hospitals just have inpatient. They don't have the outpatient clinics. And then we have our diabetes care group and this group, they do go into doctor's offices. So they kind of travel around. They have a base. I believe it's with an endocrinologist, but then they also will travel to different doctor's offices. And some of them are PCPs. Well, they they'll go there once a week. So that's kind of a neat model. And the doctors really like, and the patients like, they know where to go. They're going to their doctor's office. But there are some limitations as far as how they can be charging. And I don't, you know, they may or may not be able to charge the same day that the physician is seeing the patient. They may have to be on a different day. So it kind of depends on their insurance, how that works. That's very encouraging for a patient to be, you know, I always kind of say that, you know, I like to work in primary care because you meet the patient in the trench. You know, it's always nice to know if somebody's right there, how much, you know, that they care about you and you don't have to be anxious about going somewhere else or finding the location or, you know, getting lost on the way to the visit, that kind of thing. If you know you're going to go to your primary care and that's your kind of home base, you feel so much more comfortable with that. We have an outpatient education center and we have referrals from primary care. We have referrals from our endocrine clinic that's in the same building. We have referrals from our maternal fetal medicine. We actually have a couple of expansion clinics and one is at what's called DHP and that's the primary care that I work at once a week. And there is also a maternal fetal medicine clinic that we provide educational services and they're going to be an expansion clinic under our ADA certification. So that's kind of how we serve different areas within our institution, primary care, maternal fetal medicine, and offer them diabetes education services. I think a great thing to bring up, we were talking about access for the uninsured or underinsured or places that perhaps just don't have the funding for staff. I think DSMES really lends itself to the virtual setting. I think a lot can be done via telehealth and the billing still stands for that at this point, particularly with technology. So those of us who, I guess, provided care through the pandemic and moved to virtual a lot, I think all of us will agree that going through a download with a patient on a shared screen where they're looking at that same download with you can be just as beneficial as having them in the room and talking about what occurred before this or after that. You know, what's different about this day? Let me show you what this green bar means and where you are and where we'd like you to get. So for those people who don't have a diabetes educator, either in their primary care practice or their endocrine practice, really as you look at those referral sources, look and, you know, some of them will say they do offer telehealth services. And I think it's a great way to connect your patients with an educator. Even things like demonstrating how to put on a CGM, if that were the barrier for your patient. I think our educators are fantastic at our center and, you know, pretty much everywhere. Demonstrating and modeling via webcam at this point. So I think that's a great opportunity as we think about those who may not have access. So it doesn't matter who answers this first. What is your biggest challenge as a CDC? Yes. I can chime in. I think that in daily patient care, it's almost always socioeconomic barriers for patients. Those are really, I think, probably true for anyone caring for people in health care, but especially people with diabetes, because all of those self-behaviors are impacted by socioeconomic barriers. And so we are really fortunate that we have a social worker dedicated to our diabetes center, and she's actually on maternity leave right now, and I don't think we've ever missed anyone more because she is such a fantastic addition. But I think regardless of whether you have access to a social worker specifically for that or not, the CDC really helps a lot because you're focused on diabetes, right? So it's not the first time you've heard someone say, I can't afford my insulin or food's short. How am I supposed to pick a healthy option when all I have is like a couple dollars at the end of the month? So I think the CDC helps with that, but certainly it's probably like one of the biggest barriers that sometimes it just seems like it's really hard to get around. I actually have to agree. That was what popped first in my mind when I was asked that question. That is tough, because I do inpatient and outpatient, and looking and trying to make sure that our patients can afford the medicine when they go home. We're always looking at those barriers and trying to find the resources for the patient. I do think that's one of the biggest challenges. And like Christina said, trying to figure out how to eat healthy, how to exercise when it's not safe for them to exercise in their neighborhood, not safe to go walking. It's all, we have to adjust to that. And I think that's one of the biggest challenges that we have to adapt that and discuss ways that they can still get some movement in, in a safe manner. I don't want to be generic, but I definitely agree. And I do think that, you know, the title of this was bridging the gap. And I know this is a technology interest group. Several of you, as we've spoken, have mentioned that the patients will really open up to you. And I think no matter who we are, where we are in life, you know, opening up, we all want to provide the right answer to the person, particularly somebody that you esteem. So if it's a physician or an NP, you know, you want to give them the answer, you know, they want. And I think as a CDC, yes, you do have a little more time with the patient, which is a huge advantage. You're able to develop a relationship and a relationship in which that person feels safe to open up and say like, Hey, I actually, you know, I've turned this off or I'm not wearing this because the alarms don't, you know, don't meet my lifestyle. It's keeping my spouse up all night or I don't have food. And that's why I'm not taking my medication, but it takes space and a relationship for people to feel comfortable. And I really think that is truly where the CDC, yes, no matter what background they come from, can work with that patient and bridge that gap. So I truly think most of our clinicians at this point agree diabetes technology can really benefit. I think the data says that. I think we all are familiar with standards of care and think, you know, we've got some amazing medications that'll be able to help prevent complications, but really making sure we're meeting that patient and developing that relationship. I truly feel like that, that is where the CDC, yes, becomes the bridge is that relational bridge with the patient. And that's, that's something technology has not been able to replace as the, the relationship between humans. I think I know I already answered, but I'm just going to try to put a positive spin on it. Cause I felt like what I said was kind of down, but I think like for Clotas and I, right, we both are CDC, yes, as we both served in more of a clinician role as well, but now have more like system level responsibilities as well. And I think we've been able to take a lot of our feedback from our CDC S's and think about like some of the socioeconomic barriers that come up a lot, how can you more systematically address these? And I bring that up because this is an ADA webinar and ADA obviously supports a lot of advocacy. And advocacy is a big part on a national level or a state level, but also within your own health system. I think sometimes the CDC S does a really good job reporting to the system. Like, Hey, my people with diabetes are having this problem. Can we find a lower cost insulin? Can we find a resource for this? I think that's a unique part of the CDC S and how more globally they can kind of address some of these things. Sometimes I was standing outside in the hallway outside a room and a primary care clinic recently. And I heard the provider say, well, you need to go to diabetes education. They're going to tell you what not to eat. And I was like, that's always a challenge for me because, you know, and so we were talking later, me and the provider, and I said, you know, I actually do forensic diabetes. So I try to assess the patient and identify all the barriers of care and all the healthcare determinants that we're going to keep them from actually accomplishing your goal for them. So it's not always about telling them what they can't eat. So ladies, I have had, this has been great. I hope the audience has enjoyed this because we did try to do something different. And we're going to continue with a couple of more slides and kind of tie this up. So we have a slide that is entitled diabetes resources for healthcare providers. These are some links that actually will give you the ability to learn a lot of information about education. The ADA has just given their Institute of Learning a facelift, and it's actually beautiful. They have a lot of neat programs. They have a program for diabetes in primary care. Of course, if you're really interested in a lot of the technology, they have the Making Diabetes Technology Work series, and these actually offer continuing education units. So that's always a good thing. The ADCS, the American Diabetes, the Association of Diabetes Care and Education Specialists, that actually is a website that has a lot of information that you can access on how to become a CDCS. They actually just released their strategic plan for 2024-2028, and they are focusing on improving access to diabetes care and education, and advancing the expertise of the CDCS, and also to grow and diversify membership. So there's probably going to be some really neat opportunities for any diabetes champion that may be in a primary care. Don't think you can't still work in your primary care and pursue a CDCS. I'm sure that your providers would really love that. Most likely, I can honestly say one of the best things that I have done professionally was actually become a member of the ADA and the ADCS. It is just a wealth of information. It is my go-to places. There's always very encouraging, supportive staff on both ends every time I call or I need something, and it's just, I love both associations. There are additional resources of some topics, because I took a brief analysis of our participants, and I noticed the gamut was very diverse. So any additional questions that you may have, just leave them in the chat, or you have our contact information. I mean, we have topics, we have informational topics to discuss anything from training your staff in DSMS, expanding reimbursable services in a primary care, developing glycemic metrics to improve your inpatient care, readying your hospital for CMS, harm measures for hyper and hypoglycemia, setting up your inpatients for a successful discharge. There are great information that we can provide you, links for the future for CDS, CDCSs in the changing landscape of health care that's coming in the near future, and any kind of ADA, ADCS technology resources we're very willing to share with you. To summarize and kind of recap, you know, we've talked a lot about the four critical times to refer to diabetes education, and I kind of look at it as we are, we have a team approach to caring for that diabetes patient from the arrival in their diabetes journey to their exodus, and like Kathy was saying, hopefully their exodus is high quality. And educating people about the roles that we play, whether it's integrating technology or promoting behavioral health, we are always looking at a four or a quadruple aim at a patient in our assessments, and we want to make their experience better, the provider's experience better. We're always wanting to improve our outcomes and lower cost in giving individualized care, and if at the end of the day, if the roles that we play, if we have met those roles, this is a great blueprint for success, like we've spoken about, assessing the barriers and social determinants of health care, easing the provider's workload, and actually helping the patient understand and implementing the care plan that the provider has come up with him. With a team approach, every touch point, whether large or small that we have, or you have, or a nurse in a primary care clinic has, can make a difference in the lives of the people with diabetes. And when I was thinking about this today, it kind of brought to mind a quote from Dalai Lama, if you think that you are too small to make a difference, try sleeping in a room with a mosquito. We really appreciate you attending this presentation. We are so happy to share something that is near and dear to our hearts, and we are very grateful for the ADA for allowing us to do this. Thank you.

PharmDs to CDCES

Bridge Between Endocrinology and Primary Care

webinar

panel of experts

CDCES role

holistic care

diabetes self-management education

CGMs

CDCES challenges