In the very early days of my nursing training, one of our classes was on “holistic” concepts of healing. We had just experienced the Love, Peace and Freedom movement of the 1960s and ‘70s – a lot of my instructors were what we would now call “old hippies.” Back in those days, we did a lot of “touchy feely” things – one of which was the benefits of therapeutic touch (TT). There were variety of research studies validating the practice of TT in nursing published in the late 1970s – early ’80s. Several of my colleagues during that time worked with the healing energy effects of touch for patients going to surgery or in pain – primarily in an effort to decrease the use of pain meds and/or to quicken the healing process.
With the advent of computers and more “hard” science, the practice of TT has been withering away. Recent studies from the early 2000s were unable to substantiate any hard scientific facts for diagnosing or healing using therapeutic touch. We now have much more sophisticated means of caring for patients – MRIs, CAT and PET scans to look into the human body; computer based algorithms to help us with determining patient risk of disease; guidelines on how to manage patient care; and agencies providing oversight to the healthcare professional as to how, when and what to do in the most cost effective manner.
As I write, I’m been home bound for 2 days now under 10 inches of snow. I live in Kentucky and we only get this much snow once decade. It’s times like these that make me think of those patients who cannot get to dialysis or just ran out of insulin the night before the snow storm. Are your patients prepared for times like these? It happens so infrequent that we can just get caught up in our usual curriculum or teaching points that we may not remember to engage in dialogue about the “what ifs”. What if you lost power for a few days? What if you were snowed in for several days? What if you had to evacuate your home?
We care so deeply about our patients that I would hate for you to have to be bundled up at home worrying if Mrs. Smith has enough medication or if Mr. Stevens has anyone to check on him.
The Kentucky Diabetes Prevention and Control Program has a section of their main page if you scroll all the way down called “Being Prepared for a Disaster”. I believe it was around the hurricane Katrina time that several of my colleagues put these resources together. Several of the items pertain to winter emergencies as well. There is even a PowerPoint that you are welcome to download and use in teaching.
For winter related challenges, talk with your patients and have a pen in hand to help them write up a plan in case they are snowed in:
-Do you have enough medication and supplies? For example: blood glucose monitoring supplies, insulin syringes, or an extra battery for your pump and monitor.
-Who can you contact in case of emergency? Several of our elderly patients may not have family nearby. When they know something like an ice storm is coming their way, have them call someone and tell them to check in on them every day.
-Do you have enough water and non-perishable food items that could last you for up to 2 weeks?
-Do you have a glucagon emergency kit?
-Do you have non-perishable foods to treat hypoglycemia?
In our county, we have a “Winter Care Program” that was activated where you can call and have the Sheriff’s office take patients to critical medical appointments, provide transportation for hospital and nursing home workers, and also have them check on elderly relatives or loved ones living alone.
What other tips do you have for discussing winter storm preparedness with your patients?
How much do we talk about international diabetes education? As a travel lover and person with type 1, I'm always interested in (and often surprised by) finding new opportunities for connection and discovery provided by this unusual aspect of my life.
Finland has the highest incidence of type 1 diabetes in the world, with a yearly rate of 57.4 cases per every 100,000 children aged 0-14 (by contrast, the United States experiences a rate of 16 cases/100,000 children 0-14 years old). While every country has its own ways of connecting with the adolescent type 1 population, there are also similarities to the strategies employed to coach those challenged with managing what can be an incredibly frustrating chronic disease.
Such was the topic of discussion when I recently talked with Ms. Sari Koski via email. Sari is the Project Manager for One Life: Diabetes, developed by the Diabetes Centre in Tampere, Finland. One Life: Diabetes offers a unique resource for teenagers with type 1 diabetes: a group called Club One. Here's some interesting information about Club One that sheds some light on how diabetes professionals in Finland offer support to adolescents with type 1:
Community is important. Sara says, "Teenagers don’t often know many other people with type 1 so they might feel different to others. That’s why they might not want to treat themselves properly. In Club One they meet others with type 1 and also a young adult who knows what it is to be a teenager with type 1 diabetes."
A peer atmosphere and a mentor to look up to for advice? Sign my teen self up! From my experience, I can see how this structure helps eliminate feelings of being ostracized and cultivates a sense of belonging in an accepting environment, ideally leading to better self-care among the teens with type 1.
Life isn't all about diabetes. Sari says the project stands out among other resources due to Club One's multifaceted approach to its programming.
"We have combined peer support, information (education) and having fun in the same package. There are resources from health care available as well. Groups have the activity (sic) that teenagers like to do."
I know that I could have used all of these elements when dealing with diabetes as a teenager!
I know from working with AADE on various projects that diabetes professionals around the world can share insight and offer ideas to one another. Learning about diabetes is a constant process for everyone involved.
Sari recommends incorporating activity when counseling teenagers about taking care of themselves and being responsible for their health.
"It is a good idea to listen to the teenagers themselves and to seek possibilities that teenagers have something to do together (sic). Education can be fun and it can be performed by doing things instead of talking and listening."
Most importantly, Club One is a place where teens feel that they belong. "Every teenager deserves to feel “normal” in some group in his / her life. In this group it is normal to measure blood sugar and to get insulin. In some other groups it might not be." It's such a powerful message, and one that's important to remember for diabetes educators around the world.
We know how important it is to participate in the care of an individual with diabetes. Yet, we are underutilized. Sure, we have a shortage of diabetes educators, if everyone with diabetes receives education. But they don’t. We, as DEs, can all help to increase awareness of our profession and what we offer.
Who needs to know about us? People with diabetes (PWD) and those affected by diabetes, referring providers, other non-referring healthcare professionals, the Diabetes Online Community (DOC), politicians at the state and national level, those in government agencies that can impact diabetes care, insurance companies (including Centers for Medicare & Medicaid Services), industries that deal with diabetes products, and the general public. Who did I forget?
Let’s look at each of these. It is a two way street for PWD, those affected by diabetes, the DOC, and the general public. People in these groups can benefit from interactions with a DE. And, DEs can also benefit when these individuals spread the word about what we can offer. I think about how pharmaceutical advertising has changed prescribing of medications. Many more people go to a healthcare provider’s visit with knowledge about medications and initiate the conversation about prescribing the medication based on advertising. Wouldn’t it be wonderful if more PWD went to their provider asking to be referred for diabetes education?
We all know that diabetes education can take more time than is practical for most healthcare providers. DEs can help primary care providers and specialists by spending the necessary time, and using our expertise, when working with a PWD. During my time with patients, I often suggest referral to other providers. There are many professionals that should know about DEs to suggest referral to diabetes education.
How about politicians? We have legislation we want to move forward. State and national politicians need to hear about DEs and the great work we do! When we make a visit or call or email or tweet, we want those involved in the legislative process to say, “Oh, yes, I know how helpful diabetes educators can be for an individual, for my constituents.”
Those that are involved with reimbursement should know how DEs can improve the life of a PWD and that we are quite cost-effective. And, we should be part of the conversation when those in the diabetes products industry are making decisions.
How can we get the word out? Do you have interactions that can promote our profession? Let’s get into the conversation, at the table, in the minds of all PWD, providers, and those who can impact diabetes care and reimbursement.
What a great start to the beginning of a new year!
Every year in late December, I look forward to the American Diabetes Association (ADA) guidelines for diabetes. The standards were released and there were several updates. However, there was one update that I was not expecting, which was the updated ADA and European Association for the Study of Diabetes (EASD) position statement on the management of hyperglycemia. I wanted to provide a brief review of the position statement.
The ADA/EASD have typically provided an update in the position statement every three years. The position statements have evolved based on new evidence, particularly newly approved antihyperglycemic agents. In the 2012 position statement, the document listed Step 1 as lifestyle modifications plus metformin for an adequate period of time (i.e. three months). Lifestyle modifications are recommended in conjunction with any pharmacologic agent. Following Step 1, additional glycemic control may be needed if desired glycemic goals have not been achieved. If so, there were five options: sulfonylureas, TZD, DPP-IV inhibitors, GLP-1 agonists or basal insulin. It should be noted that if the person's A1C is above 9%, then dual therapy is the direct option. Now, these organizations have updated the standards to include SGLT2 inhibitors as a sixth option for dual therapy.
In comparison, the American Association of Clinical Endocrinology (AACE) published an algorithm in April 2013. This organization has similarities, such as lifestyle modification plus metformin as first-line therapy. However, AACE recommends a hierarchy of medications for dual or triple therapy. The hierarchy is based on the clinical evidence; within this algorithm, if a patient’s A1C remains above 7.5% after three months, then the hierarchy can be followed in this specific order: GLP-1 agonists, DPP-IV inhibitors, TZD, SGLT2 inhibitors, basal insulin, colesevelam, bromocriptine, alpha-glucosidase inhibitors, and sulfonylureas.
Both of these guidelines recommend certain factors that should be considered for the medication options; these factors include degree of hyperglycemia, the risk of hypoglycemia, cost, effects on weight, and patient preference.
There are other updates in the ADA/EASD 2015 position statement, which include less stringent prescribing of metformin (based on glomerular filtration rate) and additional details on insulin initiation and titration.
If you have not had a chance to read the position statement, you can get a free electronic copy of the document from Diabetes Care. However, if you have read and reviewed the position statement, what are your thoughts?