Strategies to Help People with Type 2 Diabetes Start and Stick to Their Diabetes Medications

Transcription

1 Strategies to Help People with Type 2 Diabetes Start and Stick to Their Diabetes Medications

2 Credentials: BSN Clinical Health Coach Certified Application Counselor (Current student:msn-informatics) Work Setting: Linn County Public Health Contact:

3 Credentials: Masters of Nursing in Health Advocacy Certified Medical Surgical Registered Nurse Certified Diabetes Educator Contact: Work Setting: UnityPoint Health (Cedar Rapids, Iowa): Combined Inpatient Glycemic Management and Outpatient Educator Non-UnityPoint Affiliated: Type2andYou.org Type2andYou with Meg (a diabetes podcast)

4 Megan Muñoz Self-Managed Stockholder in Tandem and Dexcom Cindy Fiester None

5 Identify the depth of the medication adherence problem in T2D Identify barriers to med adherence in T2D Identify at least two techniques that can be applied to practice to improve medication adherence Identify at least one resource that can impact medication adherence outcomes

6 Cost is a major, recognized barrier for medication adherence for patients. However, this presentation is focused on adherence techniques assuming cost has been addressed.

7 I knowwww it s hard after lunch!

8 American Diabetes Association (2019). Overcoming Therapeutic Inertia: Summary of Proceedings. Retrieved from Edelman, Steven V. and Polonsky, William H. Type 2 Diabetes in the Real World: The Elusive Nature of Glycemic Control. Diabetes Care 2017 Nov; 40(11):

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10 Nelson, L. A., Wallston, K. A., Kripalani, S., LeStourgeon, L. M., Williamson, S. E., & Mayberry, L. S. (2018). Assessing barriers to diabetes medication adherence using the Information-Motivation-Behavioral skills model. Diabetes research and clinical practice, 142, doi: /j.diabres Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?. Mayo Clinic proceedings, 86(4), doi: /mcp Most Common Patient Reported Barriers: Diabetes Burnout Forgetting Medication Doses Not Seeing Immediate Benefit in Blood Sugars Brand Name is Perceived as More Effective than Generic Concern for side effects

11 Medication Management and Safety Assessments Linn County State Innovation Model Grant

12 Number of Respondents = 57 Hospital (n = 30), Primary Care Clinic (n = 19), FQHC (n = 18), Public Health, Free Clinic, Diabetes Center, Specialty Clinic, Pharmacy Provider, Nurse, Care Coordinator, Educator or Health Coach, Pharmacist/Resident, Social Worker, CEO, Clinical Manager

13 A majority of participants (87.7%) state that their organization does provide medication education Most commonly believed to be provided by provider, nurse, or pharmacist. However, no clear staff role responsible or protocol established for providing education Typically 2-5 minutes is spent on education. Time constraint played a significant role for 59.7% of respondents Teach-back was the most common strategy for ensuring patient understanding (64.9%) 75% of Providers note that they Always or Usually use teach-back

14 30% 28% 25% 23% 20% 19% 15% 14% 12% 10% 5% 4% 0% Very Good Good Acceptable Poor Very Poor Does Not Apply

15 A majority of respondents state that their organization does not have a protocol or process in place to confirm medication adherence (52.6%); an additional 19.3% of respondents were not sure if their organization had a protocol in place. Personal processes Ask at appointment (56.9%) Pharmacy Verification (39.2%) Involve other members of care team (11.8%) Discuss barriers with individual (9.8%) Contact patient (9.8%)

16 Automatic refills 29.2% Private Counseling 25.0% Med Pack programs 20.8% Medication Delivery 12.5% Med Syn programs 12.5% 0% 5% 10% 15% 20% 25% 30% 35%

17 A majority of respondents (77.8%) state that they regularly ask patients about external barriers to taking their medications. Care Coordinator, Social Worker, Health Coach: 87.5% Providers: 82.1% Nurses: 66.7%

18 SOCIAL DETERMINANTS Cost (n = 41; 75.9%) Uninsured/Underinsured Lack of Available Finances Competing Priorities Social Stressors Basic Needs (ex: Housing, food, bills) Transportation EIHC and Hospital patients particularly OTHER Misunderstanding (n = 23; 42.6%) When to start meds How often meds need to be taken Purpose and importance of taking meds Possible side effects Lack of Motivation Forget to take medications

19 ANCILLARY REFERRALS Process for referral differed between organizations and at times respondents in same organization Respondents associated with EIHC were most likely to agree on a specific process for referral; including staff responsible for handling TRIGGER TO DIABETES EDUCATION New Diagnosis A1C Lack of Engagement/Compliance Change in health status Lack of Achievement Does not apply Patient Requests Referral Physician Discretion 8.8% 7.0% 7.0% 3.5% 61.4% 56.1% 75.4% 84.2% 0% 20% 40% 60% 80% 100%

20 Identify staff person responsible for providing medication education Educate staff on agency practices and protocols Formalize and improve the process for, Providing medication education Tracking and identifying medication adherence Referring patients to external resources including diabetes education Communicating patient information between discharging hospital and clinics (particularly for those without interfacing software)

21 March 2018

22 Routine and Organization Helpful Opportunity: Med Pack program Misunderstanding of Medications Side Effects* Dosage* Timing* Storage Importance and purpose* Stop when feel better* Change dose when feel needed* Communication Poor or no instruction on taking med. Providers do not listen Providers and clinics do not communicate with one another Medication changes not communicated following discharge Inaccurate medication list at different providers

23 Medication Barriers Cost* Transportation* Rural locale Physical Limitations Pharmacy Refills delayed Different refill schedules Opportunity: Med Sync and Medication Delivery Programs Price differences between pharmacies Care Coordination Care coordinator or advocate assists with barriers, improving medication understanding and adherence Want care coordination system

24 We get it, Megan and Cindy.it s a problem. But what do we do??

25 Help Decrease the Diabetes Self-Care Burden PWD is ABLE to Make an Informed Decision vs an Emotional Decision PWD Feels of Equal Importance on Their Healthcare Team

26 Trialing Interventions Changing the Narrative Understanding PWD Perspectives

27 NO ONE says Sign me up for a new kidney and a fake leg.

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30 Cost Potential SE Timing

31 He got off all meds. But it s not working for me. What am I doing wrong?? She takes insulin. She should ve taken better care of herself. I would never let myself get that bad.

32 PWD-Perceived Success Weight loss Little to no need for medication Any medication use other than insulin Science-Based Reality Sustained weight loss near 2-5% success rate Only about 15% manage diabetes w/o medication Healthy BG, BP, and Cholesterol lead to great outcomes regardless of medication type or body size CDC. (

33 Our Language Has Lasting Impacts

34 We Don t Give Credit Where Credit is Due Pulmonary HTN Using Regular Insulin OTC Distrust of Medical Pick System Up Insulin From Pharmacy Asked to Quit Work Pay out of Pocket for Forced Insulinto Move in With Mom Take Time to Take Insulin Shame Doses and Guilt around using Check Glucose Levels state-funded Life expectancy assistance 6 months-1 year Continue Despite the Hasn t Negative seen PCP Impacts of Hypoglycemia Regular for 10+ years Hypoglycemia Cardiomyopathy

35 Trialing Interventions Changing the Narrative Understanding PWD Perspectives

36 We are their healthcare team. They are not our patient.

37 empathy is of unquestionable importance No thank you put those glasses back up and pat my back! Affective empathy and partnership have the two largest impacts on patient adherence. Ranking higher even than expertise. Kim, S. S., Kaplowitz, S., & Johnston, M. V. (2004). The Effects of Physician Empathy on Patient Satisfaction and Compliance. Evaluation & the Health Professions, 27(3),

38 How well do you think your diabetes plan is working? Tell me your biggest concern about your diabetes plan right now. LISTENING IS KEY Have you had to stop your medications for any reason? Many people struggle with taking their medications, how often do you miss doses? Are you noticing side effects of your medications?

39 Roadblocks/Resistance

40 Refuse initiation of insulin or other new medications Can t take more than X units of insulin without having a low blood sugar Going to start lifestyle changes soon aka a diet program next month, gym next week, etc. Want to try lifestyle changes for longer before meds Don t feel any different (not checking glucose) know how their body feels with blood sugars and it feels fine Diabetes denial Diabetes burnout

41 I know you d like to wait on medications until you start your weight loss program next month, but your blood sugars are too unhealthy to wait. We can always decrease or stop medications as your body changes. Your A1c is at an unhealthy level. I d like to talk through some options on how we can start getting your blood sugar into healthier ranges. Your body isn t the same at 60 as it is at 20, so it would be unrealistic if we expected your diabetes needs to stay the same too.

42 Trialing Interventions Changing the Narrative Understanding PWD Perspectives

43 1. Demonstrate a Need/Make It Visible 2. Maximize Current Regimen 3. Explore New Med Options Together 4. Trialing Technique 5. Maximize Glucose Checking 6. DSMT

44 Review their medical evidence WITH them: Blood glucose logs Labs BP A1c trends Kidney function Cholesterol Link reported med adherence to outcomes (without shaming them) Their medical evidence is used to reinforce their view that plan is working OR help them identify a need for new one The Metformin Struggle

45 How much could you impact someone s A1C level by showing them their lab result and discussing it with them? Chapin, R. B., Williams, D. C., & Adair, R. F. (2003). Diabetes control improved when inner-city patients received graphic feedback about glycosylated hemoglobin levels. Journal of general internal medicine, 18(2), doi: /j x

46 Extended Release/Long Half-Life Meds-20-30% Combination Meds-26% Medication Pocketcards (FREE): ket-cards-insulin-anddiabetes-medication/ Extend this to HTN 000/0515/p3049.html Co-pay Cards, Prescription Ass. Programs Blister Packaging 90 Day Supply Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?. Mayo Clinic proceedings, 86(4), doi: /mcp Kripalani S, Yao X, Haynes RB. Interventions to Enhance Medication Adherence in Chronic Medical Conditions: A Systematic Review. Arch Intern Med. 2007;167(6): doi: /archinte

47 Current Regimen: Glimepiride 2 mg/daily Metformin 1000 mg BID Victoza 1.2 mg/day Tresiba 18 units/day New Regimen: Metformin ER 2000 mg daily GLP-1/Insulin Combo (Xultophy or Soliqua)

48 Explore New Medication Options Together

49 What does the conversation look like? Other health conditions (cardiac, renal, diabetes complications) Age/#of Meds/Length of Time You ve Had Diabetes A1c Use Medication Sheets and/or Discuss Risk/Benefits of Top 2 Verify insurance coverage/cost of the top 2 patient & provider preferred choices

50 1. The Trialing Technique 1. Maximize Glucose Checking 2. Follow-Up/Review Patient-Gathered Evidence 2. Diabetes Self-Management Training

51 It s Working SMARTER Not HARDER

52 Trialing is effective because it turns: Long-term into short-term Allows for medication or lifestyle failure without guilt Sets up opportunity for patient-identified success Gives PWD room to move through guilt, fear, uncertainty Allows you to troubleshoot any barriers to adherence (cost, pain on injection, s/e) Sets realistic expectations

53 Ask if they d be willing to trial the medication for X amount of time and come back to see you. The Good The Bad

54 Discuss important aspects: How to use and store medication Potential side effects/benefits When to expect blood sugars to be impacted (Use Medication Sheet here or any visual/discussion that helps them better understand what to expect)

55 Glucose Checking Have them check glucose at times blood sugar will be most impacted TIP: Have them check at times blood sugars will be mostly affected for three days without meds and then do it three days when med has taken near-max effect

56 Example A: Traditional Fasting Post Breakfast Pre Lunch Example B: Targeted Pre Supper Bedtime Fasting Post Breakfast Pre Lunch Pre Supper Bedtime

57 MOST people will come back with improved glucose levels or improved level of engagement when doing this form of checking MOST people will extend the med adherence behavior into other times of the day Can be applied to ANY self-care behavior

58 Create a Follow Up Plan Bring back their gathered evidence Schedule when medication will be effective

59 Stay True to Your Word: Good, Bad, and What do you think? How did it go? What worked, what didn t work? Reinforce positive behaviors and support making invisible -----VISIBLE (use patientgathered data) Intervene on barriers to continued use of medication--dsmt

60 Is A Process NOT an Event POOF!

61 The things they feared are not so bad (ex: an injection) Benefit outweighs the burden They can finally reduce stress about blood sugars (they see healthier ones!) Improved quality of life Less burnout More likely to be active in their other diabetes cares

62 What if PWD always wants to put off med start until next visit because they want to continue working on diet and exercise? Can t take more than x units at meal?

63 What If They Come Back and Still Say NO!

64 Realistic expectations (75% in range) remove perfection expectations Risk vs benefit (not maximizing cost of med etc) Dosing rapid with largest meal only Dexcom G6 alarms

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67 2018 by American Diabetes Association Melanie J. Davies et al. Dia Care 2018;41:

68 Improved BP and lipids Lower BMI Improvements in depression Lowers A1c 1-2% Reduced Healthcare costs Reduced Hospitalizations/ ER visits More likely to meet self-care goals

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70 2018 by American Diabetes Association Melanie J. Davies et al. Dia Care 2018;41:

71 Medication Makeovers At minimum on an annual basis, or anytime a new med is added, review meds to see if any: -can be combined together -can be switched to extended release -can be timed differently to reduce the number of times a day they need to be taken -can be reduced or stopped -interact with one another -are available in generic versions -if the brand name medications have a copay card (discount card) that can be applied