Recommendations for connecting patients with type 2 diabetes with the resources needed to ensure best practices, including a certified diabetes educator.
Troy Trygstad, PharmD, MBA, PhD: What’s so neat about this conversation is that we really are talking about a holistic type of circumstance. So even in the instance of stress management, we’re talking about cortisol, and we’re getting hungry. It creates a vicious cycle. We think about work-life balance.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Depression is another big one.
Troy Trygstad, PharmD, MBA, PhD: Diabetes is a symptom of modern life, maybe more so than anything. In the community, you’re discharging patients or working with patients 10, 15, 20, 30 miles away, at the VA [Veterans Affairs hospital]. Do you make an assessment of resources available? Is the local YMCA doing something for diabetes prevention? Do you have access to a wellness center? I mean, how are you sort of coaching them into this extended-care team?
Jessica L. Kerr, PharmD: Dhiren and I are kind of in that perfect world, because the VA does readily work with team partners. We do have our whole health team that is going out. We have patients who will then have classes at the YMCA. So it is really a good system for our veterans. Now, whether or not I see that happening with my own family members and their primary care services—I have not seen that level get brought up at this point.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I would say we practice in a bubble. Despite some of the stuff that you might see out there, the care that our veterans are getting is next to none. I’m a CDE [certified diabetes educator], but there are days for which I have a 15-minute slot or a 30-minute slot. I can’t do the nutrition piece, but I can make sure that I have someone walk that person down to the nutritionist and ensure that there’s someone available to see that same patient on that same day, so there’s not another appointment to just carve out a slot, or have someone ready to kind of do a warm handoff. And so we’re very fortunate to have those resources.
Troy Trygstad, PharmD, MBA, PhD: So let’s pretend that you’re filling out a budget for this next year, and you want to have all your staff be certified diabetes educators. Susan, make the best case you can to the CFO [chief financial officer] that that’s a worthwhile endeavor.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Well, I’m fortunate that I don’t have to worry about that because I’m definitely siloed away from that. Working in a free clinic, we work by donations for the most part.
Troy Trygstad, PharmD, MBA, PhD: Make the case to your donors.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: Yes. In a former life, I actually was able to plead this case. One of the biggest things is that being a CDE provides you with the tools needed, once again, to educate the patient. Just because a patient is told to do something doesn’t mean they’re going to do it. So we work with the patient to develop a care plan that fits their needs. There’s the frequent follow-through, or there should be. And obviously reimbursement for these services is available through third-party payers. What is that reimbursement? That probably could be improved a little bit, but that’s pretty well across the board.
I believe as we go more into value-based care [that we should start] to look at what we are meeting: Are we meeting our metrics? This is where a CDE will be very important. It will take some of the burden off the prescriber to do that education. So again, it goes back to the team-based care. If we have everybody on the team, the educator is there to provide that education in a format the patient can understand. Most providers don’t have that amount of time. They don’t have the time to do that.
Troy Trygstad, PharmD, MBA, PhD: Jess, who should be a CDE in the system? Everybody? Some of us?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I was going to chime in and say that if it was me, I would make the case against this. If I was a CFO, I would not. And this is coming from someone who is a CDE. You know the paying points, and you know the tools and resources. But if I had X amount of money, I would not spend my pool having everyone go through a credential exam. There are a lot of better uses of resources that could happen. I mean, you could bring in Sue and teach all the pharmacists who are there.
Troy Trygstad, PharmD, MBA, PhD: Who’s ideal? Ideal, then, would be all the pharmacists, some of the pharmacists, pharmacists in your clinic, pharmacists in the community?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Yes.
Troy Trygstad, PharmD, MBA, PhD: You said a word or term that I love, which is care planning. Is it the folks who are most likely to be involved in the care planning, and really we’re talking about meds?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Right. The same way we teach students and residents and fellows, they all don’t walk away from our rotations being certified diabetes educators, but they have the skill set that’s needed. Now, what I can’t talk to is the reimbursement piece—if that ROI [return on investment] makes sense—again, because we’re not in that billing capacity. But I would say that there are a lot of resources, especially anything that you can do to take care outside those 6 to 7 times that you might see a patient. There’s a ton that is happening outside the clinic doors. Some of those resources that then go outside to telehealth, and being able to engage a patient outside, I think would be of more benefit or value.
Troy Trygstad, PharmD, MBA, PhD: That’s interesting. So if you’ve got a 50-mile radius of patients, and if there were 100 pharmacies out there and 30 of them had a CDE, would you be more likely to refer them to those pharmacies that have the CDE?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Sure, because I know that there’s someone who has gone through that training, and I know that person is there who I could send someone to, even not knowing a relationship.
Troy Trygstad, PharmD, MBA, PhD: They’re more likely to know how to use the products. They’re more likely to be well versed in it. They stay up to date.
Jessica L. Kerr, PharmD: But I think it comes down to your own personal and professional development. We have so many nationwide, in a network of pharmacy coaches, our pharmacist coaches, who essentially may be doing the exact same job of a CDE or a BC-ADM [board certified—advanced diabetes management] without that credential behind them. So it’s really the passion that comes into wanting to serve that population.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: And the referral.
Jessica L. Kerr, PharmD: And the referral. Now, from an outside standpoint, yes, I think that CDE does give more weight to those referring providers. And so I could see the need to at least have 1 team have at least 1 CDE involved if you’re wanting to increase referrals. But whether or not you know entry-level pharmacists can…do the job, that’s not the question. They’re baseline trained like that in their curricula.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: You travel a lot. You’ve talked to a lot of independent pharmacies. There are some great pharmacists that are doing diabetes care, and they might not have a CDE credential, but I think that point that you bring up is if you’re trying to go to an endocrinology practice and are saying, “Send your patients to me,” I think that helps in those discussions. But there are plenty of them who have done it without that.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: And I think it’s important to realize too that the CDE, or even the BC-ADM, is not specific to pharmacists. There are nurses, dietitians, physicians, dentists, physical therapists. So there are other people or other disciplines that can get this. So that’s 1 of the nice things about it. It is kind of a multidiscipline credential, and it has, again, the baseline of what is needed to meet this credential, but it can be held by various disciplines.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: It sounds to me like pharmacists are the minority.
Susan Cornell, PharmD, CDE, FAPhA, FAADE: We are.
Troy Trygstad, PharmD, MBA, PhD: So it sounds to me like what you’re saying is, “Here are your medications and your plan of care,” but part of that prescribing is, “Hey, I want you to meet with a diabetes educator or equivalent,” and that becomes part of the prescribing, except it’s prescribing a service or a coach.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: At the end of the day, it’s that frequency of touch points. There could be a...
Troy Trygstad, PharmD, MBA, PhD: But is that a best practice for you? For all your patients you endeavor—obviously you’re a CDE so you’re doing that—to make sure that the patient has access to that education? Is that part of your planning and discharge process?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: A lot of my interactions are instances in which once I have that initial visit, I don’t know if I necessarily need to see that patient for every single visit. There are certain scenarios in which, if I can get those pieces of information, I might be able to save them some gas money and save them that trip. It’s not ideal, but it’s 60 miles each way. You’ve got to kind of meet the patient where they’re at.
Troy Trygstad, PharmD, MBA, PhD: Sure. And every clinic has no-show rates.