August 2016 Issue

August 2016 Issue

2016 Q3 Diabetes Tech Talk: Managing hypoglycemia with Dr. George Grunberger

Diabetes Tech Talk:
Managing hypoglycemia with Dr. George Grunberger


Dr. George Grunberger, AACE President

In a recent issue of In the Know, Dr. George Grunberger shared his valuable insights on the future of diabetes technology. In this issue Dr. Grunberger discusses how technology can help patients with diabetes prevent and manage hypoglycemia? There's no better person to ask than Dr. George Grunberger, MD, FACP, FACE!

Q: How does hypoglycemia affect the lives of your patients?

Hypoglycemia is the most feared complication of diabetes. For patients on hypoglycemic drugs like insulin and sulfonylureas, it can have a huge impact. Once people experience hypoglycemia, they're scared and will do anything possible to avoid it. Defensive eating is a classic example, such as the bedtime or midnight snack patients eat to avoid getting hypoglycemia at night. People gain weight and blame it on their insulin, but it's really the extra food they're eating.

Also, hypoglycemia affects people's productivity at work because of the things they do to avoid, minimize, or treat their hypoglycemia. People have to miss days from work or school and severe hypoglycemia might take 24 hours before blood sugar is normal. Besides absenteeism, there's presentism. This term refers to people showing up for work but not performing to their full potential. When people with diabetes are going into hypoglycemia, they have no choice but to treat it. Yet this involves so many tasks: There's glucose monitoring to confirm the symptoms are hypoglycemia. Then the patient has to treat it by consuming an appropriate glucose source. Then there's the finger stick again to confirm it's resolved. So there are costs in terms of both the materials and the time it takes, to detect, to treat, and to confirm the result.

Q: What strategies can people use to help avoid hypoglycemia at the office or at school?

There are easy answers and more complicated answers. The easy answer is to be on a continuous glucose monitor (CGM). In the 21st century, there's no excuse for people with type 1 diabetes or on insulin therapy not to be on CGM. Considering the cost of hypoglycemia, the cost of CGM, while not small, is worth it, because if you're on CGM, you know when you're heading toward hypoglycemia so you can act to avoid it. People who don't use CGM have to wait until they have symptoms, then do a finger stick to document whether or not they have hypoglycemia. If you have CGM, the CGM can help predict that your blood sugar might drop too low and take measures to avoid it.

There's also a lot of education involved. When patients are getting hypoglycemia, they need to identify when it occurs. Is it in the middle of the night or in the early morning before they eat? Then they have to deal with the basal insulin. If it happens during the day, especially between meals, typically it's because people misjudged insulin requirements for the particular meal. People on pumps or multiple daily insulin injections (MDI) have to decide at that moment how much insulin to give to cover their meal. They have to know the carbohydrate content and glycemic effects of the meal and their blood glucose value before they eat because they will have to calculate the correction factors.

It takes education, education, education. Remember, it's the patient who is making the decision in the moment. However, the diabetes educator's role in patient education is critical to ensuring the patient understands how to do insulin dosing.

Q: What advice should educators give to patients about dealing with nocturnal hypoglycemia?

With CGM, the patient sets the low and high levels. If the CGM detects glucose below the low glucose alarm level set by the patient, it will make noise and hopefully wake up the patient.

A lot of systems are on the market that integrate CGM and the pump, but only one currently has a low glucose threshold suspend system. In most systems with an integrated pump and CGM, the alarm sounds but the pump doesn't stop infusing insulin. If the patient ignores the alarm or sleeps through the alarm, the pump keeps going. In the system with the threshold suspend, the CGM not only sounds the alarm, but it also stops insulin delivery for up to 2 hours if the patient doesn't respond. It's the only one that's integrated and actually stops insulin so the patient doesn't get into worse trouble.

Q: What advice would you give educators to pass onto patients for dealing with nocturnal hypoglycemia if they don't have threshold suspend or even CGM?

For people who don't have CGM, like it or not, any time the patient adjusts insulin, whether they're on the pump or just injections, they must set the alarm clock and check their blood sugars at 2:00 or 3:00 a.m.—when blood sugar is usually the lowest—to make sure they're not getting nocturnal hypoglycemia. A lot of times they're asymptomatic and don't wake up. For those who do have CGM, the only advice is to review the records and see whether they show nocturnal hypoglycemia. The next step would be to reduce the basal insulin. If the basal insulin is an injection, then reduce the basal insulin dose. If it's a pump, then decrease the basal rate.


George Grunberger, MD, FACP, FACE, established Grunberger Diabetes Institute in Bloomfield Hills, Michigan, in 2002. He is also Clinical Professor of Internal Medicine and Molecular Medicine & Genetics at Wayne State University School of Medicine and Professor of Medicine at Oakland University William Beaumont School of Medicine. As tenured Full Professor at Wayne in 1986, he established and directed the Diabetes Program at the Detroit Medical Center and the University's Comprehensive Diabetes Center until 2002. He served as Director of Center for Molecular Medicine & Genetics (1997-2001) and Interim Chairman of Internal Medicine at Wayne and Physician-in-Chief of the Detroit Medical Center (1995-1996). He completed endocrinology & metabolism fellowship at the Diabetes Branch of NIDDK/NIH where he stayed on as Senior Investigator until 1986. Dr. Grunberger did his internal medicine residency at University Hospitals of Cleveland and received his M.D. ('77) at New York University School of Medicine and B.A. at Columbia College ('73) in New York City. In 2015, Dr. Grunberger was appointed as Visiting Professor in the First Faculty of Medicine at Charles University in Prague.

His AACE activities include six years as national Board member, an officer of the organization since 2014, and membership on multiple committees and councils (e.g., Coding, Nominating, Intensive Insulin Management, Continuous Glucose Monitoring, Diabetes Scientific, Public and Media Relations, Clinical and Practice Management Initiatives, Educational Initiatives, CAP Steering, and Clinical Research).

Dr. Grunberger served as chair of the Finance, Chapters, 2012 Annual Meeting Program, Task Force on Insulin Pump Management, PCP Diabetes Initiative, and FDA Issues committees.

He currently chairs the FDA Subcommittee, Primary Care Physician Education Committee and the Task Force for the Reimbursement of International Education Programs. He chaired the Consensus Conference on Glucose Monitoring in September 2014 and serves as co-chair for the Corporate AACE Partnership Steering Committee and Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan. He served locally as the Michigan AACE Chapter President for six years and has been active in other professional organizations.

2016 Q3 Value-Based Healthcare: How will it help patients

Value-Based Healthcare:

How will it help patients?


Value-Based Healthcare

Keeping up with changes in the delivery of healthcare is as much a challenge for manufacturers as it is for diabetes educators who see patients everyday. However, we all have the same goals - helping patients with diabetes manage their disease better, and live healthier, fuller lives. For this issue, we chatted with Suzanne Winter, Group Vice President of Americas Region for Medtronic Diabetes, to gain insights into how Medtronic is working to meet these goals.

Q: Value-based healthcare is an emerging concept in the healthcare field. Can you explain value-based healthcare as it relates to diabetes management?

VALUE-BASED HEALTHCARE: NEW APPROACH TO DIABETES CARE

Value-based healthcare is driving change in the healthcare market place. The approach is based on the assumption that healthcare products, services and solutions deliver a positive impact, not only on clinical outcomes, but on patient satisfaction and improved economic outcomes. Increasingly, payment methods are being designed based on value-based methods and away from traditional fee-for-service.

As a company, we are taking the lead in our approach to value-based healthcare. Omar Ishrak, our CEO, has been a true pioneer and visible industry leader on this topic. We try to guide our discussions with payers, providers, employers and government to ensure our goals are aligned.

Ultimately we want to be measured not only by providing therapy, but also by the impact on clinical and economic outcomes. It’s exciting to help provide a standardized approach across our businesses that tap into knowledge, assets and resources to support the healthcare system for patient success.

The opportunity to improve is real, especially in diabetes. Despite the investment and innovation, we see increasing incidence in diabetes diagnosis and a massive cost impact to the healthcare systems, including costs associated with: pharmacy, readmissions, and complications due to diabetes. This means we need to assess how we are managing the diabetes population and look for ways to improve care. Improving the quality of care through continued technological innovation, providing increasing access to care, and an integrated care will ultimately lead to improving the costs of care and patient satisfaction.

Q: What solutions are your teams focused on to drive value-based healthcare? How do you see this impacting healthcare?

IMPACT THROUGH TURNING POINT SOLUTIONS

The Diabetes Service and Solutions Business Unit (BU) and the Non-Intensive Therapy BU have developed turning point solutions that are aimed at driving integrated care and patient engagement and adherence. There are currently three areas that we are approaching:

  1. Preventing readmissions due to diabetes/post-acute care
  2. Glycemic control
  3. Therapy optimization in type 1 and type 2

As we all know, diabetes is a disease that is largely self-managed up to 90% of the time. A patient sees their doctor for approximately 10 minutes every 90 days. Doctors can provide a plethora of information in a short amount of time. After the patient leaves, they are on their own to self-manage and making hundreds of decisions a day to manage their disease. Diabetes is also a data driven disease. The turning point solutions provide a health coach tool to encourage patient engagement so that patients are more inclined to adhere to the clinical plan. The goal is to increase patient engagement and adherence, which should improve overall glycemic control, and prevent readmissions due to a diabetic event.

Another exciting solution for the care team is iPro, professional CGM. It is a critical diagnostic tool that provides a retrospective look at the patient’s CGM profile. This facilitates patients and their care team to work together to identify and address treatment needs or determine how current therapy is performing. These are just a few, and as a company, we will continue to strive to provide reduced costs and improve outcomes.

Q: What is an integrated health system? How can it positively impact diabetes educators?

EDUCATORS: OUR ADVISORS, OUR TEACHERS

Integrated health delivery networks (IDNs) are large health systems that serve a market. IDNs include hospitals, clinics, physician groups, acute care and outpatient facilities. There are approximately 500 health systems across the nation and each with own strategies of delivering care to communities. Most face the same challenges with diabetes patients:

  • Endocrinologists offices are overwhelmed with patient demands
  • Primary care offices are seeing the majority of type 2 patients
  • Pharmacy costs are one of the fastest growing areas of payer costs
  • Patients discharged from hospitals are overwhelmed with navigating the healthcare system and follow-up instructions
  • Care throughout the healthcare system is not standardized and inefficient

We formed a team to work directly with the IDNs, payers, care delivery organizations, and employers to help optimize the coordination of care for patients through our devices and solutions. As such, a critical partner in this process will be our outstanding network of diabetes educators who can help us connect the dots on standardizing care. Educators play a big role – they are in the forefront actively involved in coordinating care. We want to partner with educators to establish the highest quality of care at all clinics at regional levels, exchange patient data across multiple health networks, and provide quality care to patients. Our goal is for patients to receive a standard of care at all clinics.

All of this is new to us, and it is different from what we have done in the past. Now more than ever, we are going to need the help from educators. We are on the same journey with the same goal: good patient outcomes and satisfaction.

Q: What has been your biggest learning experience throughout this process?

It’s been amazing to see the response from the health system. Together, we are all excited for the opportunity to transform and move away from fragmented care. Everyone understands that we can do it better and more effectively. It has been amazing to see the innovation in healthcare delivery. For instance, many healthcare systems are creating roles like Chief Innovation Office or Vice President of Population Health. I have seen new administrators coming from Disney and IDEO with “out of box” thinking and consumer focused mindset to approach integrated care for healthcare systems. Why is this happening? To date, patients are required to orbit and navigate the healthcare system to achieve quality care. Now, healthcare systems are focused on patients and putting the patient in the center.

We understand that clinical pathways are important, however, care must be individualized for each patient for optimal outcomes and behavior change. For us, it presents a real opportunity to provide our tremendous expertise in diabetes care, advanced technology, resources, and to help systems and educators achieve what they want to achieve. This is where we see an opportunity to work together, and we are very excited to see the transformation unfold.


Suzanne Winter, Group Vice President of Americas Region, joined Medtronic in July 2015 and is responsible for partnering with region and business unit leaders to provide innovative, long-term business and market development strategies aimed at working together to help more patients gain access to diabetes solutions and therapies in the U.S., Canada and Latin America. She is also responsible for advancing relationships with key customers, including government, payers, physicians, and strategic partners.

Suzanne came to Medtronic from GE Healthcare, where she most recently served as General Manager of the Detection and Guidance Solutions division and was responsible for the US Sales and Marketing organization. Prior to GE, she served as VP, Worldwide Sales, Marketing and Service at Alsius Corporation, and was Director of the Ultrasound Business Unit for Toshiba America Medical Systems, and held positions of increasing responsibility for Hewlett Packard Medical Products Group, where she led worldwide product introductions, including development of marketing, pricing, sales strategy, and training programs.

Suzanne earned a B.S. in Chemistry from Saint Lawrence University and an MBA from Harvard University Graduate School of Business.

2016 Q3 Simplify, Satisfy, and Succeed: Strategy for patients and educators

Simplify, Satisfy, and Succeed:

Strategy for patients and educators

By Elizabeth Nardacci, MS, FNP-BC, CDE

Simplify, Satisfy, and Succeed

Every diabetes educator knows that diabetes standards of care call for individualizing each patient’s diabetes management plan, but knowing what to do isn’t the same as knowing how to do it. These concerns came to mind when Medtronic asked me to serve as guest editor of this issue of In the Know and to write about process efficiency. If you work in a factory, you maximize efficiency by standardizing each process, but in healthcare, it’s the opposite. We maximize efficiency by engaging patients and working with them to define individual goals and strategies. This improves patient satisfaction, which in turn helps ensure positive outcomes.

When I’m meeting with my patients, I always bear in mind three tactics for fostering patient engagement:

  • Simplify: by utilizing technology and implementing efficient protocols and processes
  • Satisfy: reduce challenges by putting patients first and maximizing care time
  • Succeed: work together to achieve success and improve outcomes

Making things easy for patients not only improves patient satisfaction but can also improve efficiency in the office, which makes the healthcare provider’s life easier too! We do this at my office by ensuring patients have a positive experience from the minute they walk into the office until they leave. As diabetes educators, we often don’t think how important the office experience is to our patients. If we can minimize wait times or provide a more comfortable learning space, we change the dynamic of the visit for the better, and patients who have a good experience are more likely to return on time for their next appointment.

How do you put patients first? Start by thinking about your own experiences as a patient when you go to see your doctor. We’ve all had a bad experience at some point—an unfriendly receptionist, or a long wait after checking in, or another long, lonely wait for the the nurse or doctor to come in and see you.

Now think about other times when the staff was helpful and friendly, and your wait times were kept to a minimum. Perhaps after the bad experience you thought how you never wanted to return to that office, while after the good one, you looked forward to your next appointment. That’s why it’s important to make the environment friendly and pleasant so patients want to come back—an important factor that helps ensure the success of our healthcare practice as a business. We need to remember, if patients don’t have a good “customer” experience, they may go to another practice or look on the Internet. That’s bad for us, and it might be bad for patients too, especially those who rely on online information that may or may not apply to them.

Communication about patients’ experience in the practice is also essential for success. In our practice, we regularly conduct patient satisfaction surveys to help us determine what we’re doing right and areas where we could improve. The latest results showed that patients appreciate concrete advice from educators about their current clinical situation. Therefore, downloading data from the patient’s devices—glucose meters, continuous glucose monitors (CGM), and insulin pumps—in an efficient manner is vital to providing a pleasant and valuable experience for the patient-customer. Our office has a dedicated person who takes the patient’s technological devices as soon as he or she checks in for the appointment. This person downloads the data from each device and provides the relevant reports for the clinician and/or educator to review with the patient (you can find information on interpreting reports here). Since our office is moving to a paperless system, we review the reports on computer screens in the exam rooms and educational spaces, but we still provide the patients with printed reports. Because the provider and patient can review the patient’s current data together at this visit, it saves time for staff to follow up if there are problems. Patients feel they are getting the attention they need immediately, and that translates into effective and efficient patient care.

In today’s changing health care environment, we need to be better stewards of our time and our patients’ time, and also look at our best practices to ensure our patients are satisfied. Technology is a very important tool to help us get there, but we should never forget to put the customer – our patients – first. When we do that, we succeed with them at achieving better diabetes management.


Elizabeth (Beth) Nardacci, MS, FNP-BC, CDE, guest editor of this issue of In the Know, is a family nurse practitioner at Capital Region Diabetes and Endocrine Care in Albany, New York. Her special interests include diabetes technologies, including professional and personal CGM and insulin pump therapy, chronic kidney disease, and renal transplantation. She is a principal investigator in the OpT2mise international pivotal trial for use of insulin pump therapy in type 2 diabetes (T2D). Beth has served as an advisor to the American Association of Clinical Endocrinologists Task Force on Continuous Glucose Monitoring. She was a recipient of the Juvenile Diabetes Research Foundation's Inspiration Award and has made numerous presentations and published clinical papers on diabetes technologies. Please send your feedback about the issue to IntheKnow@medtronic.com.

2016 Q3 Simple tools for diabetes management: Less time on hassles and more time on patient care

Simple tools for diabetes management:

Less time on hassles and more time on patient care


Simple tools for diabetes management

How often do you feel like there is just not enough time? You’re constantly juggling patient care, education and training, follow-ups, clinic schedules–it never ends! As Elizabeth Nardacci advised in her introduction to this issue, keeping things simple helps improve your efficiency. This installment of Pointers and Pearls focuses on simple tools you can use to help your patients manage their diabetes.

TRY BEFORE YOU BUY:

Six-week pump trial program lets patients test the therapy

Have you ever had a patient who wasn’t sure if a pump was right for them? In this issue’s Collaborate to Educate, Sara Lasker, MEd, MCHES, RMA, CDE, talks about a patient who didn’t want to use a pump until he’d tried one. Pump Trial is a free six-week trial that lets new patients ‘test-drive’ a pump before committing to the therapy. That way, patients can find out first-hand how the pump works and feels and get hands-on experience with all its features.

“My patient was a farmer in need of insulin pump therapy to control his glucose. He did not want to wear a pump and thought it would interfere with his job duties. I offered him the trial, which gave him first-hand experience in managing his diabetes. He found that it fit perfectly into his busy lifestyle. This program is perfect for patients that are hesitant!” - Anniece Spencer, DNP, NP-C, BC-ADM

WHEN YOU CAN’T BE THERE FOR YOUR PATIENTS:

Whenever, wherever services and solutions for educators and patients: The StartRightSM Program

Once your patient has decided to start using a pump, he or she may need a lot of help and support. The StartRight program helps educators in two important ways: First, StartRight staff proactively calls patients immediately after their product has shipped and help them prepare. That way, when a new pump patient walks into your office for a training session, they’re ready to learn. Once the patient is wearing the pump, the StartRight staff are available 24/7 for the next three to six months. They’ll answer product-related questions, order supplies, and encourage regular CareLink® data uploads. This can help free up your time to focus on diabetes management issues as well as save you from answering those midnight calls about infusion set insertion!

GO PAPERLESS:

Deliver better care with better data delivery

Waiting for data to download from devices and be printed out in reports can bog down your day. Technical problems and delays can back up your schedule, lengthening wait times for your patients and making everyone frustrated. MiniMed Connect helps to eliminate the need for manual pump downloads during patients’ office visits. It links a pump and CGM system to an iPhone® or iPod touch® and automatically sends patients’ data to CareLink® Personal, allowing your patients and your office to easily access the data, analyze trends and patterns, and make informed decisions about the treatment.

SAFETY FIRST:

SMARTGUARD™ Technology takes action when patients need it most

Helping patients stay safe is one of our most important jobs as diabetes educators. We all hate to hear a patient has had an episode of severe hypoglycemia, and it’s particularly scary for patients and healthcare providers when those episodes occur at night, while the patient was sleeping. The MiniMed 530G system can give educators and patients peace of mind. This system provides advanced diabetes control with SmartGuard™ technology that takes action and automatically pauses insulin delivery when sensor glucose values reach a preset low threshold and the patient does not respond.

Key features include:

  • Reduce lows without increasing A1C*
  • Drives action to keep patients within their target range
  • Clinically proven to reduce nighttime low blood glucose
  • Can pause insulin delivery for up to two hours, giving patients time to recover


2016 Q3 Tips on creating efficiency and improving office processes: Insights and best practices from educators

Tips on creating efficiency and improving office processes:

Insights and best practices from educators


Tips on creating efficiency and improving office processes

The theme of this issue is process efficiency. As Elizabeth Nardacci pointed out in her introduction, putting patients first can actually improve efficiency in the clinic. In a past issue, we shared insights and best practices from educators on practice efficiency for integrated pump therapy training. In this installment, we’ve brought together three diabetes educator (DE) thought leaders to share secrets on how they help patients navigate their individual challenges in self-management of diabetes.

Featuring:

KELLY HENRY, RN, CDE has been a registered nurse for more than 30 years working primarily in Franklin and Hampshire counties in Massachusetts. She started her career in nursing at Franklin Medical Center as a staff nurse. She then moved to a community setting with the Greenfield Health Center, Kaiser Permanente, where she worked for 12 years as a treatment nurse, performing a wide range of medical assessments and therapies for patients. This role involved educating patients on an assortment of topics including self-care and treatment of diabetes. In 1996, she started working exclusively in diabetes, eventually gaining her certification as a diabetes educator in 1998. Kelly is now the diabetes program coordinator at the Cooley Dickinson Medical Group Diabetes Center, previously known as the Center of Excellence in Diabetes Education, which she co-founded with Dr. Jeffrey Korff in 2001. Kelly believes strongly in educating and supporting those affected by diabetes, helping them learn how to fit diabetes into their daily lives without it over taking their life. She also believes people with diabetes should choose how to lead their life, and she supports those choices by ensuring that they and their family members have the knowledge needed to make informed decisions about their care. In her time off, Kelly enjoys biking, hiking, snowshoeing and spending time with her husband and children.

LESLEY KELNER, RD, LDN, CDE is the owner of Diabetes & Nutrition Counseling Services, LLC, where she provides Medical Nutrition Therapy and insulin pump/CGM training exclusively for those with diabetes. Based in Levittown, PA, Lesley sees patients of all ages referred by primary care physicians and endocrinologists in her area. Lesley has been an insulin pump/CGM trainer for approximately 17 years.

SARA LASKER, MEd, MCHES, RMA, CDE is a Certified Health Education Specialist based in Wisconsin. She holds a master’s degree in Health Education with a special focus on Eating Disorders from Plymouth State University in New Hampshire. Sara has worked in a variety of diabetes roles during her career at the University of Washington Diabetes Care Center and for the American Diabetes Association. She loves to volunteer her time during the summer months at diabetes camp. Sara has been involved in the diabetes community for more than 30 years and has personally been using Medtronic MiniMed products for the past 15 years.

Q: What are some of the ways you have created protocol to meet the needs for each individualized patient?

HELP PATIENTS SUCCEED IN SELF-MANAGEMENT OF DIABETES

"I feel that every patient is different with their individualized needs and try to meet those needs as best I can. I strongly believe while there is some uniformity to the education, we need to also provide individualized focus and education to help them succeed in self-management of their diabetes. Diabetes is only a part of them and if we don’t take that into account and provide time on each patient, we will not give them the true support they need to succeed. With that said, we do have a basic plan for those who will start or upgrade pump and/or CGM to ensure people get all the education and support they need through the process, but also tailor education so that it meets the needs of every patient.”

–KELLY HENRY, RN, CDE

EMPHASIZE SAFETY WHILE BUILDING CONFIDENCE

“Each patient is an individual with a different knowledge base and background. It is important to address their concerns while keeping them safe. While working with a patient I want to help build their self-confidence while preparing them toward self-care, thus, I follow general guidelines but safety is the biggest priority.”

–SARA LASKER, MEd, MCHES, RMA, CDE

Q: How do you help patients transition to a new treatment approach such as an insulin pump or continuous glucose monitor (CGM)?

COMBINE INDIVDUAL ASSESSMENT WITH GROUP EDUCATION

“All patients meet with me initially to decide how we should proceed with their unique needs, whether they are starting pump or CGM. This allows me to get to know them and see what their needs are so together we can formulate a plan. Then in our practice they typically attend a class, “Diabetes Tech 101” to learn about pump therapy and CGM use as well as share the systems available with them. After this there is a combination of individual and group sessions with me to actually start the pump, CGM or combination of the two. The number of appointments and the speed at which we move is all dependent on the patient and what fits their needs and learning style best. Also through the whole process they have direct access to me, including evenings and weekends.”

–KELLY HENRY, RN, CDE

START EARLY AND MAINTAIN CONTACT, AND SAVE TIME IN THE LONG RUN

“Early referrals work best because I can provide self management education early, and introduce them to carb counting, use of a carb ratio and sensitivity, and active insulin while on injections. During these interactions we discuss the pros and cons of CSII [continuous subcutaneous insulin infusion]. I show them how a pump is set up, how an infusion set is placed and worn and discuss any of their concerns about wearing the pump. Patients have many misconceptions about the pump, and for many being able to see the pump and how it is actually worn and maintained before they get one helps to ease a lot of their anxiety and concerns.

I also maintain contact with patients during the initial start up. I speak to them daily for a few days. I think that this also relieves a lot of anxiety. If I spend more time in the beginning making sure the patient is comfortable and knowledgeable, and the patient does well, then the physician will feel more confident with the therapy and continue to refer more patients to me.”

–LESLEY KELNER, RD, LDN, CDE

COACH THE PATIENT TO BUILD STRENGTH AND CONFIDENCE

“I personally like to take the role of coach. I work with the patient to make the transition as easy as possible by addressing their biggest concerns and those concerns they may not have thought of yet. Because each patient has a different understanding, learning curve, and appreciates support in a different way, it is important for me to know the patient. Like a strong coach, you see where the patient is struggling and give suggestions in a variety of ways so they can find the technique that works best for them. Additionally, just like training for an athletic event, the more you practice the better you become at maneuvering the insulin pump and planning for the unexpected.”

–SARA LASKER, MEd, MCHES, RMA, CDE

Q. Can you share some success stories with us where your strategy paid off?

DON’T TEAR PATIENTS DOWN; BUILD THEM UP

“There was a 21-year-old woman who came into our office from another practice. She was struggling with frequent low blood glucose (BG) and wanted an insulin pump, but had been told she was not a candidate for pump therapy because she would have to more frequently test her BG and improve her glucose control first. At the other diabetes center, she was made to feel bad and whatever she did was not enough. She stated she hated to go because they were so hard on her. She and I worked together for several months and she is now on an insulin pump, testing her BG 4 to 8 times per day and her BG control has a much better pattern with tighter control, less lows and highs. She is also feeling much better about herself.”

–KELLY HENRY, RN, CDE

BE FLEXIBLE WITH EDUCATION TO OVERCOME BARRIERS

“A patient did not want to go on the pump because he believed it would be in the way while he worked as a mechanic, and he also did not think that he could do carb counting. I did a pump demo, discussed different ways to wear it and provided carb counting education. He was much more open to Continuous Subcutaneous Insulin Infusion (CSII) once he saw the pump and learned more about how it worked. On subsequent visits the patient and I worked together with carb counting but he never got comfortable with his ability to do it. I did not want this to be a reason for him to not try CSII. I discussed with the physician the use of set bolus amount with meals and snacks (with added correction for elevated BG pre meals). Physician agreed. Patient has now been on his pump for two weeks he is doing so much better with CSII than multiple daily injections (MDI) because he is now willing to dose insulin for all carbs eaten. We use a Dual Wave® bolus in the evening for dinner and his bedtime snack, and he gets a steady basal rate, which can be adjusted to meet his needs. (BG) average went from greater than 300 prior to our working together, to 185 prior to CSII, and now at 157 on CSII for 2 weeks. We are still making adjustments to his rates and he will start CGM in a few weeks. He states that he does not know why he didn't do it sooner and that he feels so much better now that his readings are better. He also tells me that he doesn't even remember that he has a pump on when he is at work.”

–LESLEY KELNER, RD, LDN, CDE

GIVE PATIENTS HANDS-ON EXPERIENCE

“I was working with a high school student-athlete who was a long-distance runner on MDI. He was having problems with low blood glucose during his longer runs. He had never been around an insulin pump and was very apprehensive about using one because he did not have an insulin pump knowledge base. However, being a tech savvy teen, he did some on-line research but had not yet had the chance to touch the buttons and put his research into practice. We talked about how an insulin pump could be helpful for him while running track and cross country because he could lower his basal rate prior to the workout and not have to consume so many glucose tabs while out on his run. By letting him sample a pump, he had the hands-on opportunity he needed to touch the buttons and see how wearing the device could benefit him during his activities. Now, by using a pump, his performance has improved, and he has been setting personal records with the need of fewer glucose tabs!”

–SARA LASKER, MEd, MCHES, RMA, CDE

Q. As a diabetes educator you spend a lot of time with patients on patient care, consultation and training. What Medtronic services or solutions help you focus more on patient education and training to achieve optimal outcomes?

PERSONAL CONTACT AND HANDS-ON TRAINING

"I find my Medtronic sales rep and clinician to be the most valuable tools I have. They are very helpful when I need information. I tend to be old fashioned and prefer a manual I can get my hands on. I find them easier to navigate but typically once I learn a product I rarely use anything. I do suggest at times that patient’s use a YouTube video, but usually if they need more than a basic manual offers I prefer using the individual tear off sheets/handouts my clinician has given me. I also tell patients about all the services Medtronic offers so they can chose what fits their learning style best.

I also think Medtronic has the best software for downloading pump and CGM. I use the CareLink® Pro and Personal software, finding both extremely valuable."

–KELLY HENRY, RN, CDE

“I use the workbooks that come with the pump, and YouTube for pump set up (making sure that they use Medtronic sponsored videos only), set insertion, and Enlite® sensor insertion. I ask patients to read sections in the workbook explaining basal and bolus prior to our first visit. We then decide what sections they should read depending on their learning needs. I do not ask them to read every section in the beginning because I want the information to be meaningful as we proceed with training. During visits, we refer to the booklets and answer the questions together. I also depend on CareLink® software for teaching the patient pattern management and food’s effect on glucose.”

–LESLEY KELNER, RD, LDN, CDE

“The most valuable tool I have used is CareLink® software. I have found through downloading a patient’s pump then sharing the results with the patient it has been very eye opening to them in terms of their diabetes management. It also starts great conversations about where they think their diabetes management is and where it actually is. It allows us to work together to tweak areas of concern as well as give them the opportunity to sample a new technique of diabetes self-management.”

–SARA LASKER, MEd, MCHES, RMA, CDE

Q. What is the best advice you would provide to a fellow educator?

GIVE EVERY PATIENT A CHANCE

“Be open minded to each patient and their needs. Try to see outside the box: the script we have been given or told to follow for a pump patient doesn’t always include those patients who will benefit most. I have found many times the patient you are most concerned about do the best because you gave them the tools they need to do the job, improving their self-care, self-esteem and glucose control.

I think we try to map out everything, define everything/everyone and/or do it by the book too often and miss great opportunities to help our patients. Best practice has to start somewhere, if it feels right and safe, try it out and see how it works. Give a patient a chance by looking at the whole person. You can’t help a patient if you don’t know anything about them or truly listen to them, their needs, issues. At the bottom of most ‘difficult’ patients are issues we can work with and work around if we figure out what they are. Along the way they learn to trust us and are more willing to work with us.”

–KELLY HENRY, RN, CDE

TREAT PROTOCOLS AS GUIDELINES THAT NEED TO BE FLEXIBLE TO MEET PATIENT NEEDS

“Let the patient guide your protocols based on their needs not yours. Some will need more hand-holding than others to feel comfortable with CSII and CGM. The more prepared and knowledgeable about diabetes self-management the patient is before they get their pump, the better they will do with pump therapy.”

–LESLEY KELNER, RD, LDN, CDE

BE WILLING TO CHANGE YOUR APPROACH WHEN NEEDED

“Monitor and revise as needed while taking advantage of teachable moments. I received similar advice my first day on the job and it has benefited me throughout my career.”

–SARA LASKER, MEd, MCHES, RMA, CDE


2016 Q3 BUZZ TALK: NEWS YOU CAN USE

BUZZ TALK:

NEWS YOU CAN USE


Buzz Talk

REIMBURSEMENT SUPPORT

In this issue we talked about how you can increase your process efficiency by putting patients first. Making sure your patients and your office get the reimbursement support they need is another way to put patients first and increase efficiency. CGM accuracy is only as good as the BG values used for calibration, and CONTOUR®NEXT LINK is the only BG meter that is labeled for use with the MiniMed® 530G with Enlite® system.

NEED REIMBURSEMENT SUPPORT?

The CONTOURSM NEXT Reimbursement Support Program provides CONTOUR®NEXT Test Strip reimbursement support for patients on a compatible Medtronic insulin pump.*

For reimbursement help, call the CONTOURSM NEXT Reimbursement Support Program today at 1.866.296.1436 M - F (8 AM - 7 PM ET) or email us at: Reimbursement@ContourNextHelp.com and a reimbursement specialist will contact you.


2016 Q3 Advisory Board

Advisory Board


  • KELLY HENRY, RN, CDE
    KELLY HENRY, RN, CDE has been a registered nurse for more than 30 years working primarily in Franklin and Hampshire counties in Massachusetts. She started her career in nursing at Franklin Medical Center as a staff nurse. She then moved to a community setting with the Greenfield Health Center, Kaiser Permanente, where she worked for 12 years as a treatment nurse, performing a wide range of medical assessments and therapies for patients. This role involved educating patients on an assortment of topics including self-care and treatment of diabetes. In 1996, she started working exclusively in diabetes, eventually gaining her certification as a diabetes educator in 1998. Kelly is now the diabetes program coordinator at the Cooley Dickinson Medical Group Diabetes Center, previously known as the Center of Excellence in Diabetes Education, which she co-founded with Dr. Jeffrey Korff in 2001. Kelly believes strongly in educating and supporting those affected by diabetes, helping them learn how to fit diabetes into their daily lives without it over taking their life. She also believes people with diabetes should choose how to lead their life, and she supports those choices by ensuring that they and their family members have the knowledge needed to make informed decisions about their care. In her time off, Kelly enjoys biking, hiking, snowshoeing and spending time with her husband and children.
  • LESLEY KELNER, RD, LDN, CDE
    LESLEY KELNER, RD, LDN, CDE is the owner of Diabetes & Nutrition Counseling Services, LLC, where she provides Medical Nutrition Therapy and insulin pump/CGM training exclusively for those with diabetes. Based in Levittown, PA, Lesley sees patients of all ages referred by primary care physicians and endocrinologists in her area. Lesley has been an insulin pump/CGM trainer for approximately 17 years.
  • SARA LASKER, MEd, MCHES, RMA, CDE
    SARA LASKER, MEd, MCHES, RMA, CDE is a Certified Health Education Specialist based in Wisconsin. She holds a master’s degree in Health Education with a special focus on Eating Disorders from Plymouth State University in New Hampshire. Sara has worked in a variety of diabetes roles during her career at the University of Washington Diabetes Care Center and for the American Diabetes Association. She loves to volunteer her time during the summer months at diabetes camp. Sara has been involved in the diabetes community for more than 30 years and has personally been using Medtronic MiniMed products for the past 15 years.
  • ELIZABETH (BETH) NARDACCI, MS, FNP-BC, CDE
    ELIZABETH (BETH) NARDACCI, MS, FNP-BC, CDE, guest editor of this issue of In the Know, is a family nurse practitioner at Capital Region Diabetes and Endocrine Care in Albany, New York. Her special interests include diabetes technologies, including professional and personal CGM and insulin pump therapy, chronic kidney disease, and renal transplantation. She is a principal investigator in the OpT2mise international pivotal trial for use of insulin pump therapy in type 2 diabetes (T2D). Beth serves as an advisor to the American Association of Clinical Endocrinologists Task Force on Continuous Glucose Monitoring. She was a recipient of the Juvenile Diabetes Research Foundation's Inspiration Award and has made numerous presentations and published clinical papers on diabetes technologies. Please send your feedback about the issue to IntheKnow@medtronic.com.
  • ANNIECE SPENCER, DNP, RN, NP-C, BC-ADM
    ANNIECE SPENCER, DNP, RN, NP-C, BC-ADM is a Diabetes Clinical Manager with Medtronic for a little over 1 year in the St. Louis North territory. She has 9 years of experience treating and educating patients with diabetes in the hospital, home and community health center settings. In her previous role as a family nurse practitioner, at a medically underserved community health center, she developed a passion for educating and treating patients with diabetes. Anniece recently received a Doctor of Nursing Practice degree with an Advanced Diabetes Management focus from The University of Alabama Birmingham in December 2015.
  • SUSAN M. WILLIAMS, RD, CDE, LDN
    SUSAN M. WILLIAMS, RD, CDE, LDN is a Registered Dietician and Certified Diabetes Educator. She also works for Medtronic as a Diabetes Clinical Manager for 8 years. She loves challenges and teaching patients about diabetes and how to manage their disease. Susan currently resides in Shrewbury, MA.