Managing the Newly Diagnosed Diabetes Pa ent Monday, June 27 9:00am - 10:00am

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1 CPE ACCESS CODE: Must redeem CPE credit by: JULY 30, 2016 at Managing the Newly Diagnosed Diabetes Pa ent Monday, June 27 9:00am - 10:00am ACPE UAN: L01-P CPE Credit: 0.1 CEUs/1.0 Hr. Ac vity Type: Applica on-based Learning Objec ves for Pharmacists: Upon comple on of this CPE ac vity, par cipants will be able to: 1. Iden fy treatment op ons for the newly diagnosed pa ent based on guidelines and pa ent specific factors 2. Discuss strategies to successfully counsel the newly diagnosed pa ent 3. Outline a stepwise process to ensure all preventa ve needs are addressed 4. Create a process within your med sync or tradi onal workflow to ensure the pa ent receives consistent follow up Nora Stelter, PharmD Nora Stelter is Associate Professor, Pharmacy Prac ce, and Coordinator, Introductory Pharmacy Prac ce Experiences (IPPE) at Drake University College of Pharmacy and Health Sciences. In her current role she delivers educa on and wellness programs to senior ci zens at senior centers in Polk County and serves as a preceptor for introductory and advanced pharmacy prac ce experiences at her site. She also coordinates IPPEs for third year student pharmacists. Dr. Stelter teaches in the Pharmacy Skills and Applica ons course series and the Self Care course and also teaches an elec ve course on Advanced Communica on Skills for student pharmacists. Prior to her current academic career, Dr. Stelter spent eight years at the Na onal Associa on of Chain Drug Stores (NACDS) where her most recent posi on was Director of Educa on and Training where she developed pharmacy educa on and training programs for chain pharmacists and managed all student programs. Dr. Stelter, a Chicago-area na ve who earned her Doctor of Pharmacy degree at the University of Iowa in 2000, gravitated toward leadership posi ons as a student with various pharmacy organiza ons. This led her to pursue a summer internship at NACDS, and upon gradua on from pharmacy school, she became NACDS first Execu ve Resident. In addi on to her responsibili es at Drake, Stelter works as a relief pharmacist at a chain pharmacy. Wendy Mobley-Bukstein, PharmD, BCACP, CDE Wendy Mobley-Bukstein is Assistant Professor of Pharmacy Prac ce in the College of Pharmacy and Health Sciences at Drake University. She received her Doctor of Pharmacy degree from Drake University in 1999 and is a Cer fied Diabetes Educator. She is APhA cer ficate trained in Diabetes Care, Immuniza on Delivery and Medica on Therapy Management. Currently, she teaches a Medica on Therapy Management elec ve, in the Pharmacy Skills and Applica ons course series and the Self Care & Nonprescrip on Products course. She maintains a clinical prac ce at Primary Health Care East Side Clinic where she precepts third year pharmacy students on their drug therapy problem solving or community introductory pharmacy prac ce experience (IPPE). Her specialty areas of prac ce and scholarship are diabetes, medica on therapy management and community educa on. Previous to joining Drake, she was the instructor for a pharmacy technician course at Heartland Community College and maintained a pharmacy prac ce at Hopedale Medical Complex in Illinois. She is the coordinator for the American Pharmacist Associa on Special Interest Group on Diabetes Management, an ac ve member of the American Associa on of Diabetes Educators and Iowa Pharmacy Associa on. Faculty Disclosure: Nora Stelter and Wendy Mobley-Bukstein report no actual or poten al conflicts of interest in rela on to this CPE ac vity.

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3 Continuing Education 2016 Managing the Newly Diagnosed Diabetes Patient Wendy Mobley-Bukstein, PharmD, BCACP, CDE Disclosure Wendy Mobley-Bukstein reports no actual or potential conflicts of interest associated with this presentation 2 1

4 Learning Objectives Upon successful completion of this activity, pharmacists should be able to: 1. Identify treatment options for the newly diagnosed patient based on guidelines and patient specific factors. 2. Discuss strategies to successfully counsel the newly diagnosed patient. 3. Outline a stepwise process to ensure all preventative needs are addressed. 4. Create a process within your med sync or traditional workflow to ensure the patient receives consistent follow up. 3 Building the Bridges to Better Health BRIDGE ENTRY: The place where the patient enters life with the chronic disease PATHWAY TO BETTER HEALTH: The patient has been given the tools and knowledge to selfmanage their disease and knows where to seek help if needed. GUARD RAIL: Education!!! Otherwise, the patient can t get across the bridge safely. SUPPORTS: Role of the healthcare team to support patient in their education and learning. 4 2

5 Reviewing the Guidelines American Diabetes Standards of Medical Care American Association of Clinical Endocrinologists Guidelines and Algorithms 2 National Standards for Diabetes Self-Management Education and Support Diabetes Care 2012 Nov; 35(11): Foundations of Care 1. Self-Management Education 2. Nutrition 3. Counseling 4. Physical Activity 5. Smoking Cessation 6. Immunizations 7. Psychosocial Care 8. Medications American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23- S35 6 3

6 Criteria for the Diagnosis of Diabetes Fasting plasma glucose (FPG) 126 mg/dl (7.0 mmol/l) OR 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT OR A1C 6.5% OR Random plasma glucose 200 mg/dl (11.1 mmol/l) American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 7 Glycemic Recommendations for Nonpregnant Adults with Diabetes A1C <7.0%* (<53 mmol/mol) Preprandial capillary plasma glucose mg/dl * ( mmol/l) Peak postprandial capillary <180 mg/dl * (<10.0 plasma glucose mmol/l) * Goals should be individualized. Postprandial glucose measurements should be made 1 2 hours after the beginning of the meal. American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 8 4

7 Diabetes Self-Management Education/Diabetes Self-Management Support Delivery VS. 9 Diabetes Self-Management Education/Diabetes Self-Management Support Delivery Four critical time points for DSME/S delivery: 1. At diagnosis 2. Annually for assessment of education, nutrition, and emotional needs 3. When new complicating factors arise that influence self-management; and 4. When transitions in care occur American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the Care 2016; 39 (Suppl. 1): S23-S35 American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S

8 Recommendations: Diabetes Self-Management Education & Support - All people with diabetes should participate in DSME and DSMS both at diagnosis and as needed thereafter. (B) - Effective self-management, improved clinical outcomes, health status, and quality-of-life are key outcomes of DSME and DSMS and should be measured and monitored as part of care. (C) - DSME/S should be patient-centered, respectful, and responsive to individual patient preferences, needs, and values that should guide clinical decisions. (A) S23-S35 American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 11 Recommendations: Diabetes Self-Management Education & Support (cont.) - DSME/S programs may have the necessary elements in their curricula that are needed to prevent the onset of diabetes; content should be tailored specifically when prevention of diabetes is the desired goal. (B) - Because DSME and DSMS can result in cost-savings and improved outcomes (B), DSME and DSMS should be adequately reimbursed by third-party payers. (E) American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23- S

9 Antihyperglycemic Therapy in Type 2 Diabetes American Diabetes Association Standards of Medical Care in Diabetes. Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1): SX

10 15 Case Examples: Identifying Risks for Complications 16 8

11 Example 1: Patient with Rx for glucose meter and test strips 17 Example 1: Patient with Rx for glucose meter and test strips 18 9

12 Example 2: Patient with Rx for glucose meter, test strips and metformin. 19 Example 2: Patient with Rx for glucose meter, test strips and metformin

13 Example 3: Patient with Rx for glucose meter, test strips, metformin and glimeperide. 21 Example 3: Patient with Rx for glucose meter, test strips, metformin and glimeperide

14 Example 4: Patient with Rx for glucose meter, test strips, metformin, insulin detemir and pen needles. 23 Example 4: Patient with Rx for glucose meter, test strips, metformin, insulin detemir and pen needles

15 25 Guide to Abbreviations on AACE slides Met= Metformin GLP-1-RA= Glucagon-like peptide-1 receptor agonist SGLT-2i= Sodium-glucose cotransporter-2 inhibitor DPP-4i= dipeptidyl peptidase-4 inhibitor AGi= alpha-glucosidase inhibitor TZD= thiazolidinedione SU= sulfonylurea GLN= glitinides COLSVL= Colesevelam BCR-QR= bromocriptine QR PRAML= pramlinitide 26 Hypo= hypoglycemia GU= genitourinary GI= gastrointestinal CHF= Congestive Heart Failure CVD= Cardiovascular Disease 13

16 27 Case #1 A patient presents to the pharmacy with a prescription for a blood glucose meter, test strips and a prescription for metformin 500mg daily for 3 days then increase to 500mg BID. Consider the following questions: 1. Based on the clinical guidelines that were just reviewed, what is the most appropriate therapy for a newly diagnosed patient with diabetes? 2. What would you want to counsel the patient about regarding diabetes? 28 14

17 Counseling the newly diagnosed patient Transtheoretical Model: Stages of Change Small doses at a time First session - Diet - Activity - Medications - Monitoring Valuable Resources American Association of Diabetes Educators (AADE) 7- Self-Care Behaviors An example of a cited process that assists in consistent education 1. Healthy Eating 2. Being Active 3. Taking Medications 4. Monitoring Blood Sugars 5. Reducing Risks 6. Problem Solving 7. Healthy Coping Accessed April 14,

18 The Medication Synchronization Process Selection of Medications The Pick-Up Patients ID and Recruitment Alignment of Meds Maintenance Opportunity 1: Identify patient eligible for services Initial patient interaction picking up new or refill Rx or diabetes supplies. 31 The Medication Synchronization Process Selection of Medications The Pick-Up Patients ID and Recruitment Alignment of Meds Maintenance Opportunity 2: Initial Appointment or Pick Up Review or teach monitoring process, Address the components of the ADA s Foundations of Care Discuss med adherence Assist patient in creating vision, short-term and long-term goals 32 16

19 The Medication Synchronization Process Selection of Medications The Pick-Up Patients ID and Recruitment Alignment of Meds Maintenance Opportunity 3: Follow-Up Appointments/Pick Ups Review monitoring and labs, continued health coaching for medication adherence, Foundations of Care, assist patient in creating new short-term goals, evaluate progress towards long-term goals 33 Reimbursement for Diabetes Self-Management Education and Support: Who Can Bill vs. Who Cannot? Who Can Bill? Registered Dietitian Physicians Who Cannot Bill? Pharmacists Certified Diabetes Educators Nurses Exercise Specialists 34 17

20 Reimbursement for Diabetes Self-Management Education and Support: What If? Pharmacy with an accredited program Hospital or clinic with an accredited program Provider status for pharmacists Provider status for CDE 35 Key Take Aways Identify opportunities in your pharmacy to build a bridge to better health Stay current with guidelines Recognize differences in guidelines Identify critical time points to provide DSME/S Create a plan for the Foundations of Care Design workflow models that integrate diabetes education, management and support 36 18

21 Continuing Education 2016 Questions? Wendy Mobley-Bukstein, PharmD, BCACP, CDE 19