When Marie Brown, MD, cares for patients with prediabetes or type 2 diabetes, they often fit a specific profile: middle-aged, with obesity and at least half a dozen comorbidities and a long list of medications.
“It’s a very complicated history and visit because you’re not dealing with one problem,” Dr. Brown, an internist and the AMA’s director of practice redesign, said during an episode of the “AMA STEPS Forward® Podcast” with Jill Jin, MD, an internist and senior physician adviser for the AMA.
Diabetes and prediabetes are often impossible to tackle alone in a 20-minute visit. And managing the care of these patients takes a village, said Dr. Brown.
During the episode, Drs. Brown and Jin discussed team-based approaches and opportunities to save time while improving the health of patients as highlighted in an AMA STEPS Forward toolkit.
Importance of a team-based approach
There are 96 million adults in the U.S. with prediabetes and 37 million with diabetes. Yet many don’t even know they have these conditions. Physicians have a responsibility to make sure that patients become aware of their condition before it gets out of control and complications develop, said Dr. Brown.
A shortage of time is one of the big challenges in managing diabetes care. Physicians have to juggle patient expectations and all t the pressure to stay on time, as well as documentation, coding and ordering on the computer.
A team-based approach addresses the many comorbidities that afflict this chronic disease such as hypertension, chronic pain, arthritis and depression, said Dr. Brown, noting that patients often have a sedentary lifestyle that continues the cycle of weight gain, depression and other problems.
The goal is for clinical teams to work together to address all these problems at the same visit and coordinate the care, noted Dr. Jin.
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Pre-visit planning saves time
Part of this strategy involves “pre-visit planning,” in which teams follow protocols, identify patients who need or qualify for screening and enter orders, Dr. Brown said in a follow up interview.
The U.S. Preventive Services Task Force recommends screening for prediabetes and type 2 diabetes in all adults 35–70 years old with obesity or who are overweight. The American Diabetes Association also has extensive screening criteria for asymptomatic adults.
If a routine HbA1c test reveals that a patient has prediabetes, the team should refer the patient to a National Diabetes Prevention Program and schedule a follow-up visit with the physician. Patients should also receive prediabetes education through the portal to ensure they are well-informed and empowered at the next visit as the team prepares next steps.
“We want that person to be activated and provide them a referral immediately to the Diabetes Prevention Program,” said Dr. Brown.
Medical assistants, nurses, physician assistants and nurse practitioners should be charged with doing the routine screenings, the so called “production work” so that the physician has time to do the “solution shop” work, addressing things such as a patient’s new symptoms or discuss weight loss, noted Dr. Brown.
Doing these steps in an organized fashion avoids fragmentation of care and better serves the patient’s needs, she emphasized. The team in turn gets back another hour or two each day.
“We have time then, with those hours saved, to dig a little deeper into the solution aspect for which we’re trained,” said Dr. Brown.
Getting teams to invest
Dr. Brown recommended several resources to get medical teams to invest in this approach. For example, the “De-implementation Checklist” (PDF) addresses ways to reduce burden such as minimizing alerts and inbox notifications.
Meanwhile, the “Getting Rid of Stupid Stuff” toolkit identifies opportunities to save an hour or two by simply removing unnecessary messages in the EHR inbox. These measures can free up the team’s time “so they can think about a team-based approach to managing our patients with chronic diseases, including prediabetes and diabetes,” said Dr. Brown.
The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage their risk of developing type 2 diabetes, including referring patients at risk to a National Diabetes Prevention Program lifestyle-change program based on their individual needs.
