Diabetes self-management is a careful balance of taking medications, eating well-balanced meals, engaging in physical activity, stress monitoring, and symptom management, among other daily tasks.
As certified diabetes educators (CDE), we are all involved in helping our patients balance everything best meet their disease management goals. Pharmacists are also an important part of diabetes self-management education and support (DSME/S), doing so much more than just dispensing medications.
I would like to showcase a best practice from my fellow CDE who has been pioneering the DSME/S as part of integrated pharmacist interventions.
Susan Cornell, BS, Pharm.D, CDE, FAPhA, FAADE is the associate director of experiential education and an associate professor in the department of Pharmacy Practice at Midwestern University Chicago College of Pharmacy in Downers Grove, Illinois. Dr. Cornell is also a clinical pharmacist consultant and certified diabetes educator, specializing in community and ambulatory care practice. She also serves as the Midwestern University American Pharmacists Association Academy of Student Pharmacists (APhA-ASP) faculty advisor and patient care project supervisor.
Q. Sue, what is the role of a pharmacist in delivering DSME/S? What are some other interventions provided by pharmacists to improve the diabetes care outcomes?
A. The pharmacist is the medication expert. In the four-year post-graduate pharmacy curriculum, pharmacists are trained to provide comprehensive medication management and education for patients. We look to verify the patient is getting the correct medication (and dose) for their disease/condition, as well as, identify drug or disease interactions the medication may have, potential side effects, contraindications, cost and/or cultural concerns, and any other barriers to adherence.
Studies have shown that more than 50% of diabetes patients will stop taking their medication(s) within the first three to six months of initial treatment. Pharmacists are in a unique position to help recognize non-adherence and work individually with patients to ascertain a behavior change plan that will meet their needs to maintain adherence (to their medication and lifestyle goals).
Q. What is new versus the same with diabetes medication theory for type 2 Diabetes?
A. There has been quite a bit of change in the diabetes pharmacotherapy armamentarium over the past 2 decades. We went from having 3 classes of drugs in 1995, to having 12 classes of drugs in 2013, with more in the pipeline.
The biggest change in the diabetes pharmacotherapy eruption is the focus on targeting (fixing) the numerous dysfunctional organs involved in the disease, while simultaneously accentuating efficaciously, weight loss/neutrality, low hypoglycaemic risk, favorable cardiovascular profiles and saving the beta cell.
In addition, studies are underway (with preliminary favorable results) that explore combination drug therapy upon diagnosis in effort to target (fix) all eight of the dysfunctional organs in type 2 diabetes. I suspect the future of diabetes pharmacotherapy treatment will be a two (or more) drug combination from the start.
The suggestion has been made to treat diabetes with the same aggressive approach as other serious diseases (such as cancer). A patient diagnosed with cancer, rarely receives the one drug “trial” approach for a few years to see if it works and then if the disease progresses, combination therapy would be considered. Patients with such diseases are assertively treated to control/eradicate the disease. The same approach should be used in type 2 diabetes.
Q. There are a few hundred pharmacists who are CDEs in the US. How can nurses, dietitians, doctors and others involved in DSME/S collaborate with pharmacist CDEs?
A. Yes, there over just under 1000 pharmacist CDEs in the United States and these pharmacists work in a variety of practice settings. In addition to the traditional community and hospital pharmacists, there has been an increase in pharmacists working in long-term care facilities; primary care medical offices and specialty care medical practice. More and more medical groups are employing pharmacists to work side-by-side with physicians, nurse practitioners, physician assistants, nurses, dieticians, and more in effort to provide comprehensive medication management and education. In essence, it is a “one stop shop” for patients. The patient can receive medical care and management, along with lifestyle and medication education from a team of healthcare professionals during one extended visit. The additive benefits of team-based care, is that all healthcare disciplines work to the level of their training and reduce the overall workload for a single provider. This approach leads to ongoing optimal patient care.
Q. What do you see as a future for pharmacists in diabetes care?
A. I see more of the team-based medical care, as I just described. We are already seeing the health-system affiliations expanding facilities and non-physician personnel to accommodate this type of patient-centered care. There is an increase in telemedicine and ongoing support/care as well. Many community and ambulatory care pharmacists are already onboard, providing a variety of innovative patient care. Through the use of technology and smart phone apps/messaging, pharmacists are able to assist patients with medication and lifestyle adherence.
Q. What can nurses, dietitians, social workers and others involved in diabetes care delivery with our patients do to best facilitate discussions about taking medication?
A. It is important to frequently assess patients for medication and lifestyle adherence. Through the use of open-ended questions, active listening and reflective responses (skills taught in most motivational interviewing courses), healthcare professionals can identify barriers and concerns in medication management. For example, asking patients the following questions at every medical/education visit can provide insight to how they are taking (or if they are taking) their medication. For each medication, the patient should be asked:
- What are you taking this medication for?
- How do you currently take it? (morning, evening, with or without food, etc)
- What problems have you noticed since you started taking this medication? (identifies side effects or barriers to taking the medicine)
- What concerns do you have about the cost of your medications?
- What do you do when you miss a dose of your medication?
a. How frequently does this happen.
Through the use of these questions, it is easy to identify cues from the patient’s responses that indicate a problem or concern. This can allow the healthcare professional to explore what is going on in the patient’s life that is resulting in not taking their medication correctly or at all.
Q. What are primary barriers and opportunities with medication-taking among people with type 2 diabetes?
A. The biggest barrier is often cost and timely access to care. Unfortunately, “cheap drugs” are chosen over “right drugs”; and ultimately the patient is the one that suffers this burden. Despite having 12 classes of medications available to treat type 2 diabetes, the oldest drugs are still prescribed due to their inexpensive cost. The newer agents, which truly target the pathophysiological defects of the disease are used infrequently, despite their superiority.
In addition, there is a severe health disparity in the United States. The increase in people without insurance or that are under-insured has grown over the past few years. Many of these people have limited or no access to healthcare. In addition, there has been a significant change from people that had optimal medication therapy to now having suboptimal treatment. For example, patients that use insulin pumps are now having to use a 75/25 mix (twice daily injection) instead due to changes in medication coverage. A backwards step in quality treatment and care.
Also, many prescribers are not referring patients for diabetes education and support care. Often, diabetes is not considered “serious” and therefore, treatment plans are less aggressive or non-existent. It is imperative to increase awareness and provide high quality education for all healthcare providers, health-systems, the public, legislative parties and patients. This is an opportunity for all CDEs and diabetes educators to become actively involved with the various diabetes groups to voice the necessity for diabetes education and ongoing support for all people with or at risk for diabetes. Together, we can make a difference in this epidemic.
Q. Is there anything else you would like to share with our network of Conversation Map users? Many of them are pharmacists, as well as from various environments of academic, retail, clinical and community settings.
A. The Conversation Maps are ideal tools to use to initiate a crucial conversation with each diabetes patient. The maps can be used in a variety of ways; such as for individual behavior modification and goal setting, as well as for group sessions. With more and more community pharmacies receiving AADE or ADA recognition for their DSME/S programs, the conversation maps are a fundamental part of the education curriculum. No matter what setting, pharmacists are a key member of the diabetes care and education team with the skills and training essential to help patients achieve their goals and live a healthy life with diabetes.