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
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.
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.”
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.”
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.”
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.”
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.”
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.”
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.”
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!”
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."
“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.”
“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.”
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.”
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.”
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.”
- Best practices: Creating efficiencies for integrated pump therapy training. Medtronic Diabetes. http://professional.medtronicdiabetes.com/diabetes-educators/best-practices-creating-efficiencies-integrated-pump-therapy-training. Accessed April 2, 2016.
- MiniMed® 530G System User Guide. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/MiniMed%20530G%20System%20User%20Guide.pdf. Accessed April 2, 2016.
- Medtronic Diabetes YouTube. Medtronic Diabetes. https://www.youtube.com/user/MedtronicDiabetes. Accessed April 2, 2016.