Typically, such teams identify potentially wasteful activities—duplication of efforts or steps that can be done in a more efficient way, or eliminated completely, without ill effect. Medical assistants could stop reconciling medications, for instance, if the primary care providers in the practice are already doing this, and use the time saved to screen patients for depression or neuropathy.
In our experience, physicians who undertake workflow analyses are often surprised to find that members of their staff have many ideas about practice improvements—and are happy to take on more work if they see that doing so would improve patient care. When our staff was reminded of how important blood pressure control is for patients with diabetes, for example, they started placing a sticky note with out-of-range numbers on the computer monitor in the exam room to ensure that this important finding would not be missed.
3. Build a multidisciplinary team
Properly managing a disorder as complex as diabetes requires a team approach. The team might include diabetes educators, nutritionists, behavioral counselors, diabetologists, ophthalmologists, nephrologists, cardiologists, and podiatrists, as well as primary care physicians and family members. Whenever possible, such team members should be integrated within the practice. When this is not the case, transparent communication is critical. A shared EHR can facilitate this.
And while sharing—and gathering—patient data such as blood glucose levels, carbohydrates consumed, intensity and duration of exercise, and daily medications can be time consuming, it is critical to do so. Data review makes it Office staff can be trained to give patients with diabetes a brief depression screen, such as the Patient Health Questionnaire (PHQ-9), at least once a year. possible to prevent acute complications associated with glucose levels that are too high or too low, for example, or to uncover patterns, such as increasing weight or abnormally low (or high) blood sugar at a particular time of day, and take timely corrective actions.
Whether such data analysis occurs within your practice or in the office of a nutritionist or other specialist, diabetes management in a primary care setting benefits from teamwork, too. Medical assistants can administer monofilament tests for neuropathy at each visit, for example, to ensure that this important screening isn’t missed. Office staff can flag the charts of patients in need of additional screening and review before the end of the visit to ensure that the requisite testing has been done. They can also facilitate previsit labs (see “Previsit labs: A simple but effective practice change” on page 546), eliminating the need to contact patients in the days after the visit to review findings and make recommendations that could have been done during the visit.
4. Screen for depression
Patients with diabetes are more likely than those who do not have diabetes to suffer from depression.13 It has also been shown that those who are depressed are less likely to have their diabetes under control than those who are not depressed,14 in part because depressed patients are not as likely to adhere to a medication regimen.15
In some cases, identifying and treating depression can be the key intervention that leads to improved diabetes management. A recent randomized controlled trial found that an integrated approach to managing diabetes and depression resulted in improvements in both glycemic control and depression.16
Without a good screening program, clinicians typically fail to identify depression in a substantial number of their patients.17 A brief screening tool, such as the Patient Health Questionnaire (PHQ-9), can reliably identify depression. Office staff can be trained to give patients with diabetes a depression screen at least once a year when they check in.
5. Screen for undiagnosed diabetes and prediabetes
The ADA recommends screening all patients ages 45 years or older for diabetes, as well as overweight adults (BMI ≥25 kg/m2) with one or more additional risk factors (TABLE).7
Screening for diabetes is effective because:
- Diabetes is prevalent (affecting nearly 26 million US residents).5
- The disease is often asymptomatic and many patients do not recognize or acknowledge their symptoms (more than a quarter of those with diabetes are undiagnosed).5
- Accurate, reliable, and inexpensive screening tests are available.
- Early identification provides opportunities for useful interventions.
Traditionally, diabetes was diagnosed by fasting plasma glucose, oral glucose tolerance tests, or—in symptomatic individuals—random glucose elevations. HbA1c was added as a recommended diagnostic test in 2009 and endorsed by the ADA in 2010, with a threshold for diagnosis of ≥6.5%.18
Patients with an HbA1c between 5.7% and 6.4% are considered to have prediabetes, according to the ADA, and have a greater risk for developing both diabetes and CV complications at the higher end of this range. Such patients should be counseled regarding diet, exercise, and other lifestyle issues; metformin should be considered, as well, for those at particularly high risk.7