Managing type 2 diabetes requires extra effort from both the patient and health care team. To help improve patient care there are simple innovative changes practices can make. A practice in Oak Park, Illinois specializes in treating patients with type 2 diabetes and uses a team-based care approach to focus on the patient as a whole, not just the disease.
In an AMA STEPS Forward™ module on managing type 2 diabetes, Marie T. Brown, MD, a geriatric and internal medicine specialist at Rush University Medical Center, explains how team-based care, improving medication adherence and treating the whole patient can help improve health outcomes.
As an internist, most of Dr. Brown’s patients have diabetes or prediabetes. However, rarely does diabetes exist alone.
“If a patient has diabetes, they usually have three to four other chronic illnesses, such as hypertension, obesity, depression or hypercholesterolemia,” Dr. Brown said. “It’s the frontline doctors that need to treat the whole patient.”
Treat the whole patient, not just the disease
When treating a patient with type 2 diabetes, physicians should look for additional conditions. If the patient is overweight, it is important to check for other conditions like depression. Reviewing the patient’s prescriptions might reveal that the patient is taking medications that promote weight gain, such as antidepressant medications, sulfonylureas and insulin.
“In a fragmented care system, the endocrinologist treats the sugar, the psychiatrist treats the depression and the heart doctor treats the hypertension, but nobody is treating the whole patient,” Dr. Brown said. “They’re so intertwined, you have to look at the patient individually and develop a plan with the patient not just for the patient.”
By treating the whole patient, underlying complications or conditions are uncovered. For example, recently Dr. Brown saw a new patient scheduled for a pre-op exam for bariatric surgery because, in addition to having type 2 diabetes, she was tired of struggling with her diet. After review, Dr. Brown found that one of the patient’s medicines promoted weight gain. Replacing that medicine, the patient lost 40 pounds over the next eight months and cancelled her bariatric surgery. The patient felt great and in control of her health for the first time in years.
“It is about treating the patient and not the glucose level,” she said. “If you treat only the glucose level, and focus only on the A1C level, who does that serve? The physician looks good, the metric looks good, but the patient might be gaining weight. This does not serve our patients well”
Celebrate success, take it slow
It is important for patients to know the health care team is in this journey with them. If the patient says they need to lose 50 pounds, it might take two or three years to accomplish. Instead, the focus should be on the patient not gaining weight over the winter. Then, in the next few months, if the patient has not gained weight, they can celebrate success.
“Many people gain five pounds a year, so avoiding weight gain truly takes effort. Celebrating that the patient was successful in not continuing to gain weight is crucial,” Dr. Brown said. “Congratulating the patient that they stopped gaining weight, may motivate them to continue their efforts and begin to lose weight. Developing a trusting long-term relationship with the physician and her team, and recognizing that managing diabetes is a life long challenge will slowly improve their health.”
“Often patients tell me they want to lose 30 pounds in three months! One of the most successful approaches I found was to ask how much they lose in a year with one month weight loss, two years and three years. When a 45 year old patient reflects that this slow weight loss will result in being 36 pounds lighter by age 48, it gives them a more realistic goal,” she added.
Gradually increasing exercise is more beneficial in the long run for patients, according to Dr. Brown. Suggest a patient start with exercising five minutes a day. While the experts say a person should exercise 150 minutes a week, it is hard to go from zero to 30 minutes a day, five days a week.
“Once they’ve exercised seven days in a row for five minutes a day, then they can increase it by two or three minutes,” Dr. Brown said. “It takes about six weeks to develop a new habit—that’s where you make lifelong changes and find reasons to celebrate success.”
It’s a team-based approach
In Dr. Brown’s office, each patient with diabetes is automatically referred to a diabetes educator. Medicare and most insurance companies cover 10 hours of training the first year a patient is diagnosed with type 2 diabetes. Every year thereafter, the patient’s insurance will usually cover two hours a year.
“If your patient meets four times a year with a diabetes educator for 30 minutes, imagine how much more efficient and effective your visit the following week is with that patient,” Dr. Brown said. “Many of their questions about diet and exercise are answered by experts who have the time to do so.”
“[Diabetes educators] are much more effective at discussing diet in a 15-minute visit—when you have other comorbidities and concerns to address is challenging,” she said. “It’s frustrating for the doctor—there’s just not enough time and when we feel rushed, we often don’t do it as effectively.”
Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.
In October 2017, the AMA announced a multistate effort aimed at reducing the incidence of type 2 diabetes nationwide. The AMA offers online CME to expand your knowledge in diabetes management. Explore educational content such as “Prevent Diabetes STAT.”
