Nursing Diagnosis Risk For

i am dr. pam allweiss,an endocrinologist with the cdc division ofdiabetes translation. i would like to welcomeyou to this webinar. today ppod is not a vegetable;it’s a wonderful team of passionate providers whohave come together to develop materials and a webinar toillustrate how team care for people with diabetescan become a reality. they energize all of us, and weare trying to walk the walk when it comes to team care.

you can see all oftheir bios on the screen. ppod providers may bethe first person who sees somebody with diabetes. our goal is to have teamcare on your radar screen. we are not trying to makeoptometrists into podiatrists. some general points:the materials are in the public domain; no copyright. please copy as you wish;download them in your office. there are materials forproviders and for patients,

which have been pilot tested inmany of our provider’s offices. for instance, we have apatient checklist that has been developed and evaluatedby our ppod providers, as well as by primarycare providers such as family practice docs,nurse practitioners, etc. everything will be availableon the web site, including the slides and therecording of this webinar. at the end, we will answergeneral questions and, eventually, all questionsthat you submit to us

will be answered. i have two requests: pleasestay connected at the end and fill out the quick surveyabout today’s webinar, and then please, please fillout the survey that will arrive in your box in a fewweeks to evaluate if there has been any change in howyou practice team care. we really need theinformation to help us evaluate what we aredoing and to improve. now, i would like to turn itover to dr. dennis frisch.

thank you, dennis. dr. frisch: thank you,and thank you, everybody, for taking some time out of yourday to learn about team care. in this section, we are going tolearn about the ndep, which is the national diabeteseducation program, the scope of diabetes in the u.s., andthe ppod team care approach: what it is andwhy it’s important. so, what is the ndep? the ndep was established in 1997as an initiative of the u.s.

department of healthand human services. it was established to promoteearly diagnosis of diabetes, improve the management of thedisease and its outcomes, and prevent and delay theonset of type 2 diabetes. the ndep is jointlysponsored by the cdc and nih. ndep brings together morethan 200 federal, state, and private sectoragency partners. we at the ndep believein the importance of team care approach to diabetes.

a team approach among ppodproviders, as well as many other health care professionals,is of crucial importance in helping patients to maintaintheir diabetes and to take the needed steps to lowerthe risk for complications, including, in our particularcase today, those related to feet, eyes, teeth, andmedication management. working together to managediabetes, a toolkit for pharmacy, podiatry, optometry,and dentistry, offers resources to support providersin this important work.

so, what is ppod? ppod is a team approachamong pharmacy, podiatry, optometry, and dentalproviders, as well as other health care professionals,and is of critical importance in helping patients to manage theirdiabetes and take the needed steps to lower the risk forcomplications, including those related to our particularfields of feet, eyes, teeth, and medication management. ppod providers are wellpositioned to deliver key

diabetes management andprevention messages, to communicate the needfor metabolic control, and encourage patients withdiabetes to see their optometrist, podiatrist,and dentist at least once a year and to reviewtheir medication therapy with a pharmacist at least annually. our ppod message emphasizes theimportance of all health care providers treatingpatients with diabetes. ppod providers havethe opportunity to educate

patients with diabetes abouttheir disease, to encourage them to practice self-management, and to provideappropriate treatment. as we’ve discussed, diabetes isa serious problem that affects many people each day in theu.s. and its territories. why is ppod important? ppod makes a differencefor patients with diabetes. not only can it providetreatment outcomes, but it can also greatly enhance apatient’s treatment experience.

a team approach to diabetescare reduces risk factors, it improves management ofthe disease, and it lowers the risk for complications thatcan result from the disease. ppod providers are in a uniqueposition to make a difference in their patients’ lives, asthey may often be the first health care provider tosee a patient experiencing a new problem. for example, a patient maycomplain of blurred vision at a visit with hisor her optometrist.

the patient may not realize thatthis can be a sign of diabetes, allowing the optometristan opportunity to ask other questions about thepatient’s condition. as a part of a ppod team, theoptometrist will be aware of the signs and symptomsof diabetes and can refer the patient to his or herprimary care provider to seek further testsand/or treatment. ppod providers are in a uniqueposition to identify signs and symptoms that could otherwise bemissed, and they may continue to

monitor a patient’s conditionat routine checkups, such as dental cleanings,dilated eye exams, and annual podiatric exams. many patients turn to theseprofessionals before consulting primary care providers withcommon diabetes questions about self-care or medications. ndep encourages all health careprofessionals to understand their unique contributionto diabetes team care so their advice topatients is consistent.

there are tremendousopportunities for getting messages about diabetescontrol and prevention. the team care approach has anumber of benefits for patients. a team approach among ppodproviders, as well as other health care professionals,allows access to integrated diabetes care across specialtyand primary care areas. a team care approach encouragesregular communication among a patient’s team of healthcare providers and emphasizes the importance of prevention.

at this point, i’m going to turnit over to sandra leal, who is going to speak to us about therole of pharmacists in ppod. dr. leal: thank you very much for the introduction,dr. frisch. this is a pleasure to be hererepresenting the pharmacist’s role in diabetes managementbecause of the importance that pharmacists can have in reallyassisting patients to be advocates fortheir own condition. and so, a couple ofreally key points about

the role of the pharmacists. they are a unique member of thehealthcare team and oftentimes, because patients are takingmultiple medications for diabetes and comorbidity, suchas blood pressure issues or cholesterol issues, they mightbe seeing their provider up to seven times more often thanother providers, so this offers a unique opportunity forthe pharmacists to be able to intervene several times duringthe year, several times during the month, even, if thepatient is coming in to

the pharmacy on those occasions. so, the pharmacist is oftenthe most accessible health care provider since there is noappointment required to see the pharmacist, andpharmacists are also available at all hours of the day. there’s 24-hours pharmacies;they’re also available in the weekends, and again, becausethere is no appointment needed, the pharmacists can play aunique role in being able to help the patient navigatethrough this condition.

some of the roles thatthe pharmacists have really taken--and the american diabetesassociation has promoted--is the role of thepharmacist in monitoring the drug medication regimen. this is really, really key,because of all the opportunities to help the patient work throughtheir plan and be able to better and more effectivelyuse their medications. the pharmacist may work with thepatient to develop a plan that reduces the side effects anddrug interactions and really

advise a patient on how totake the medication properly. the pharmacist may also help thepatient with other things that are very important to control,and one of the things that’s very key are things aroundmedication affordability. with all the medications that apatient takes, sometimes this is a key intervention thatthe pharmacist really takes a lead on, and trying to helpassist the patient in being able to afford not onlymedications, but things like testing supplies that theymight need to better control

their medication regimen. another big key role thatthe pharmacist can play is communicating withthe health care team. sometimes the pharmacist is theone that contacts the provider on behalf of the patient orencourages a patient to schedule other appointments that mightbe necessary, like followup for an eye exam or a foot exam,if the patient is communicating some of these issueswith the pharmacist. some of the key questions to askyour patients about medication

therapy management, as you areseeing a patient, and really an opportunity to refer tothe pharmacist, are related to these questionsthat are listed below. so, the patient should bereferred to a pharmacist if the answer to anyof these questions are “no” or “unsure.” “do you have a list ofall your medications, vitamins, and supplements?” if you are seeing apatient and they don’t have

a good knowledge of whatthe medications are or the indications for themedications, the pharmacist can really work to help developa medication list with the patient that makes sensefor them and is current and is updated on a regular basis. “do you know the reasons whyyou take each medication?” again, the indicationis very key. sometimes you’ll see apatient bringing bottles to your appointments, andyou’ll find that, you know,

you ask them, “why are youtaking this medication for?” and they say, “well, i’m notsure, the doctor prescribed that for me, and i don’t reallyknow what that’s for.” so, that would beanother key trigger to say, “you know, this might be anopportunity for you to work with your pharmacist to getmore information about why you’re taking medication.” “have you reportedany side effects from your medication toyour pharmacist?”

sometimes patients willreport that they stopped taking a medication orthat it makes them have bad side effects from it. it’s another key to findalternatives for the patient that’s necessary, or to workthrough some of the concerns that they’re having. “do you have anydifficulty affording your medicationsand testing supplies?” again, very key with thepopulation that we are serving,

especially because thereare so many medications that the patient might be taking, andthe testing supplies might be something that is actuallypreventing them from really obtaining good control. and another key question is, “doyou understand the importance of timing your medication inrelation to your meals?” and i think this iseven more important when a person is on insulin. sometimes, they may be takingthe insulin after they eat or

several minutes to hoursbefore they eat, which might be actually causingadverse events for them. and a pharmacist can really bekey in helping them understand the timing of the meals, theimportance of adherence to the medication, andreally understanding how the medication regimenis working for them. this is an example of ppod inaction, so if a patient comes in--this is a 40-year-old womanwho notices blurry vision and asks her pharmacistabout reading glasses.

the pharmacist discovers thatthe patient was diagnosed with diabetes last year, but didnot return for followup visit. the pharmacist advises thatchanges in vision may be a sign of diabetes and nota need for reading glasses. and we see this quite a bitin practice, where patients are looking for some readers. they might be complainingof needing to go to the ophthalmologist, whenin reality the cause is high blood sugar and, withbetter control, they could

actually avoid that tremendouscost of obtaining glasses that might not work forthem once their blood sugar isin better control. but this is an opportunityfor the pharmacist to step in, arrange a primary carevisit or a visit with the ophthalmologist, or both,and really help the patient be an advocate for themselvesand have better control. so, pharmacists can alsorefer her to the ndep web site, which is listed aswww.cdc.gov/diabetes/ndep

for more materials. but again, a lot of ways tointervene on multiple occasions because of the multipleopportunities to see the patient, and that wouldreally serve the patient a continuous and a consistentmessage as they have to continue to navigatethis chronic condition. thank you. i will pass it down todr. javier la fontaine, who is a podiatrist.

dr. la fontaine: goodafternoon to everybody. one of the other keymembers of the team is obviously the podiatrist. diabetes leads to 60 percentof the nontraumatic lower limb amputations, and diabetes perse increases the chance of amputation, as i just mentioned. but fortunately, thosepatients with diabetes who are involved inroutine foot care will have treatable foot careproblems, and therefore

we could essentiallyincrease prevention this way. ulcerations are very common;they lead to amputation. unfortunately, once weget these ulcers healed, they often re-ulcerate. up to 80 percent of themwill re-ulcerate in 12 months. so this is an ongoingproblem that we need to treat. and we need to doaggressive prevention, and the patient needsto be aware of this. successfully, if a patient isinvolved in a routine foot care

program, over 80 percent ofthese ulcers can be preventable, and therefore we can decreaseulceration and amputations. this is how an ulcer is goingto look, and usually these ulcers do come up inthe bottom of the foot… …because the main problem thatpeople with diabetes get is what we call the “critical triad,” which is neuropathy,deformity, and trauma. so, trying to identifythese patients at risk will decrease ulceration.

neuropathy is the most importantcomponent that leads to ulceration, so therefore thatis the number one target that we are actually trying toaccomplish on prevention. and obviously, blood flow isalso an important component, because once you get a wound,you essentially need good blood flow to get it healed up. so, we are going to identifythose patients with neuropathy. that is what we can, as appod member, podiatrists, we can help you identify thesepatients with neuropathy,

vascular disease, and deformity. you know neuropathy, likeyou probably all know, is essentially the nerve damagethat occurs in diabetes, but often this patient is goingto come in to your office and they are just simplygoing to tell you, “my feet are numb.” they are going to have othersymptoms that may lead you that they do have neuropathy:like tingling in the feet, pins and needles in their feet,either burning, shooting pains.

sometimes, their feet get reallysensitive to anything--to touch, heat, cold--sometimes theydo come up and tell you “i do have numbness.” you obviously don’t need tolearn this, but once you refer the patient to us andwe are going to identify this patient with neuropathy, this is what we aregoing to do for the patient. just simply do tests. we are going to feel forvibration, which is the fastest

sensation that disappearson patients with diabetes. we do that with a tuning forkand we do touch with a filament, which will help us identifythose patients that are lacking the touch sensation. we are also going toscreen for vascular disease. so essentially, just like inthis picture, it is going to essentially show you how wepalpate for the pulses, you know the dorsal [inaudible] andthe posterior pulse, and if we notice that these are absent,then we do the appropriate

referral to a vascular surgeon. and last but not least, theseare some of the deformities we are going to be able toidentify for the patient, so: bunion, thickened toenails,ingrown toenails, history of amputation, toedeformities, etc. essentially, we canidentify this and educate the patient as well, andprovide them appropriate shoes. you can see on the pictureon the top, identifies that somebody with a bunion on theright foot like this, and is

unable to perceive a tight shoe,it is going to lead to an ulcer. but, you know, obviously, it is not that simplefor the patients. so, some of the questionsthat you can ask the patients. if they tell you “no”or they are unsure, they are very simple. “did you get a full exam by apodiatrist at least once a year? do you know how diabetescan affect your feet, and do you know how to checkyour feet every day?”

if you ask these three questionsand they answer to you “no” or “unsure, wecan just make a simple referral to the podiatrist,and we can take it from there and educate the patientand categorize it and put it on their risk level, and thereforecontinue the appropriate referral for these patients. now, this is a laundry list. you obviously don’tneed to memorize this. but if you want to ask thesepatients a little bit more about

their degree of neuropathy orvascular disease, then we can ask them these questions, like: “are your feet numb? do you have burningpain sensation? are you sensitive to touch?” a lot of the patientsthink that is normal for them, since it has been happeningfor two, three years, so just triggering them to thinkabout some of these questions. then you will be able to furtheridentify these patients at risk

and then do the proper referral. again this is a laundry list,this is going to be in the materials that you can downloadfrom the ndep web site and the ppod link, so thisshould be easy for you to keep in your office. now, some of the questionsyou are going to get from patients are“why are my feet numb?” and i just essentiallygave you the answer, and they are essentially havingsome symptoms of neuropathy.

“my legs hurt when i wake. what could cause that?” or “my legs gettired very easily.” those are usually signsof neuropathy, or it can be a sign of vasculardisease, so again, these questions arekey for making the proper referral for the patient. “i have a callus on my foot,what should i do?” obviously, we don’t want thepatient messing with it, so

maybe making the properreferral to the podiatrist, that would be also animportant referral to do. and last but not least,“i have an ingrown toenail, should i see a podiatrist?” the answer is yes. “why are my legs swollen?” obviously, leg swellingcan be due to neuropathy, can be due to vascular disease, but it could bemany other problems

like kidney disease, liverdisease, heart disease. so, you know again, theseare some of the questions that you are going toget from the patient. these are probablythe most common ones i see in my practice, soany of these questions should trigger a proper referralto a ppod or podiatrist. thank you, and i think iam going to leave you with paul chous, which isthe optometry part of the ppod team.

dr. chous: well thank youvery much; that was really a fantastic presentation. i’m going to talk a bitabout eye health and optometry’s role in that. it remains a fact that diabetesis still the leading cause of new blindness amongstworking age americans less than 74 years old. the estimates are somewherebetween 15,000 and 25,000 americans becomeblind, principally from

diabetic retinopathy, each year. in addition, about 11 percentof adults with diabetes have some form of vision impairment, which ranges frommild to severe. now, it can be somethingas simple as an improper glasses prescription, andin fact, the majority of patients with visionthat is subnormal in the diabetes populationcan be corrected by having an updated refraction done.

many of the eye complicationsof diabetes, especially diabetic retinopathyand glaucoma as well; these are painless conditionsand may cause few or no symptoms until the eye disease hasprogressed to a stage where treatment may befar less effective. and this is really a key messagefor all of us ppod providers: good vision on an eyechart does not mean that patients don’t haveserious eye disease. patient surveys suggest thatfear of losing vision concerns

people more than any otherdiabetes complication. health care providers need to beaware that the increased risk of depression amongst those withvision loss is readily apparent to those of us whoprovide their eye care. adults with loss of visionfunction are about 90 percent more likely to haveclinical depression than those without vision loss. in addition, these patients areat increased risk for falls that result in fracture aswell as, at some point,

requiring nursing home care. health care providers need to beaware that patients with loss of vision from diabetes can oftenbe helped by seeing eye care providers who specialize in theprescription and dispensing of low vision aids specificallydesigned and customized for various degrees ofvisual impairment. this is a whole separatesubspecialty within my profession, called lowvision, helping people with significant vision loss.

let’s talk about annualeye exams for a moment. people with diabetes canmaintain optimal vision and healthy eyes by having an annualcomprehensive vision examination that includes a dilatedretinal examination. with early interventionof retinopathy or other serious ocularcomplications of diabetes, such as glaucoma, are found. doctors of optometry routinelyperform these tests and many others, including sophisticatedimaging of the retina on

our patients with diabetesand other health conditions. we have a couple of imageshere, just depicting diabetic retinopathy on the left,with dot and blot hemorrhages throughout the retina, and tothe right is an optical coherent tomography scan, kind ofan optical cross-section of the retina,showing fluid edemas. so this is a patient withdiabetic macular edema. often these patientshave good visual acuity. more than 90 percent of visionloss caused by diabetes can be

avoided with good diabetesmanagement, including the abcs of gooddiabetes care: good a1c, good blood pressure, control ofblood lipids, and avoidance of smoking, and early detectionand timely treatment. it is really important torealize that eye disease caused by diabetes isoften associated with other complications, includingcardiovascular, podiatric, and periodontal disease. this fact reallyunderscores the importance of

a collaborativeteam care approach. the other things that are muchmore common in our patients with diabetes arethings like dry eye. so if the other providers seepatients that are complaining that their vision isfluctuating constantly and they have red eyes--alot of patients with diabetes have dry eye. about twice as common inpeople with diabetes than the rest of the population.

this is something that eyecare providers can really help them with, and it’salso a sign, oftentimes, of autonomic neuropathy. a lot of patients won’thave symptoms of dry eye, their eyes will be red, butthey’re not as symptomatic as their nondiabeticcounterparts would be. let’s look at some of thekey questions we should all be asking ourpatients about eye health. by asking some of these simplequestions, larger issues can be

uncovered that could bepotential red flags for good management of diabetes. if patients are answering “no”or are unsure about the answers to any of these questions, itis recommended that they be referred to their optometrist toseek further care, counseling, and, if necessary, treatmentor referral for treatment. in my experience, one of the keyconcepts that we all need to be aware of, is that goodvision, as i said, does not mean there are no serious eyecomplications from diabetes.

i got diabetes wheni was 5 years old. i had perfect visionuntil i was 21. i went in to see my optometrist,who saw bleeding in my eyes. i got treatment. i had perfect visionon the eye charts, but vision-threatening eye disease. i see patients all the timewith severe, sight-threatening diabetic retinopathy, as wellas glaucoma that can rob them of vision, who are able to read20/20 or better on the eye chart

at the time they are diagnosedwith their eye disease. this is a reality thatunderscores the importance of regular eye examinations,even in patients with no visual problems. here’s a good exampleof ppod in action. in this example, there’sa situation in which a ppod provider uses a routinevisit as a way to engage in a broader dialogue withthe patient, and in this particular case, thepatient’s daughter.

having knowledge aboutdiabetes and its risk factors, the eye care professional knowsthe patient’s daughter is also at increased risk for developingdiabetes and is able to provide the family with an ndepbrochure, and is able to advise the patient’s daughterto make a followup appointment with her own primarycare physician to be screened for diabetes. additionally, theoptometrist knows that diabetic retinopathy is presentin one of five newly diagnosed

patients with type 2 diabetes. that’s a profound statistic. so, patients with type 1diabetes don’t have retinopathy at diagnosis; theyhave had the disease for a relatively shortperiod of time. but we all know by the timea patient is diagnosed with type 2 diabetes, they havehad the disease oftentimes for between 5 and 8 years,and that’s why retinopathy, even severe retinopathy,can be present at diagnosis.

it’s so important to referpatients for eye examinations, even if theirvision is fluctuating. you want to wait on prescribingglasses for patients because their hemoglobin a1c is high;these patients still need to be evaluated for the presence ofsight-threatening eye disease. the other factor that isexamined in this case is the optometrist recommends that thedaughter of the patient also get an eye exam, because africanamericans past the age of 40, in particular, are atdramatically increased

risk for glaucoma, which isanother leading cause of blindness, especiallyamong black americans. oral health and diabetes. even though oral healthcomplications are very commonly associated with diabetes,we can find that 85 percent of patients with type 2 diabetesreport they have not received any information onthe association between diabetes and oral health. in turn, this extendsall the way into the

health careprofessional community. many health care providers havelittle to no training about the oral, systemichealth association. diabetes and periodontal diseaseis a two-way relationship. periodontal disease is abacterial infection with inflammatory complications. that systemic inflammationsignals increases in blood sugar levels. also, like any other infection,it can impair the body’s ability

to process or toutilize insulin. on the other hand, diabetes doesnot cause periodontal disease, but it is a leadingcomplication of diabetes. diabetes lowers the resistanceto infection and greatly increases a person’ssusceptibility of developing periodontitis. in turn, that periodontaldisease makes it more difficult to control blood sugar levels,so it is a two-way relationship. it’s certainly associated withthe poor glycemic control.

in addition, tobacco useand poor nutrition are also risk factors forcompromised oral health. ppod providers canhelp change this. as they collaborate with othermembers of this health care team, we can reduce the ratesof periodontal disease and other oral health conditions. oral health exams. diabetes patients really shouldbe encouraged to adhere to annual oral examinations.

the recall interval for oralpatients is really determined specifically for eachpatient according to his or her needsand risk assessment. the management of periodontaldisease in people with diabetes can result in significantreduction in a1c numbers, so people with diabetes reallyshould be encouraged to have perio disease treated toeliminate infection and for the aid in metabolic control. dental visits can also be usedas an opportunity to educate

patients and to begin a dialogwith the low-risk patients in order to prevent themfrom becoming high risk. dental professionals are alsocomfortable discussing the relationship betweenoral health and nutrition. these opportunities can alsobe used to affect the stem of obesity and itsrelationship to diabetes. key questions to ask yourpatients about oral health. people with diabetes are oftennot aware of the significance of diabetes and poor health.

as i have stated, the healthcare provider whole entire network does not seem tobe very familiar with the oral-systemic link. by asking patients a fewsimple questions about their oral health, larger issuesmay be uncovered that could be potential red flags for themanagement of their diabetes. if patients answer “no” or“unsure” about the answers to any of these questions, it isrecommended to please refer them to their dental provider toseek further direction in care.

ask them if they hadvisited their dental provider within the last year. ask them if they know howimportant the relationship is and how the effects can be intheir mouth and if they really do know the early signs oftooth, mouth, and gum problems. healthy teeth do matter. so an exampleabout ppod in action. managing diabetes medicationscertainly can be complicated, and it is also confusing fordiabetes patients to understand

how to adjust their medicationaround certain events, such as a dental procedure. for a patient who has to havea dental procedure scheduled, the dental professional mightrecognize that the patient is really unsure how to managetheir insulin injection, and because she istold that before the dental procedureshe should not eat. so to provide direction for thepatient, the dental professional arranges a pharmacyconsultation for her to

resolve any unansweredquestions and ensure that the procedure does not interferewith her needed medications. she can call the pharmacist. the pharmacist can help herwork around not eating and when her insulin injectionshould be taken. i have treated many patientswith diabetes and have spoken to other dental professionalswho can attest to the fact that many, many people outthere need the intervention of dentistry, along with thecollaborative effect with

other health care providers. once again, healthyteeth do matter. and i thank you and i takeyou back to dr. frisch. thank you everybody, and thankyou for the presentations. what we are going to do now, youhave emailed some questions in on the chat box, and also,we got a bunch of questions on the pre-survey questionnaire. what we are going to do istry to parse them out to the different presenters andremind everybody that if

we don’t get to your question,we will answer them. over the next month or so, weare going to break these out into the different providers,and they will get an email and they are all busy practitioners,so please give them a little bit of leeway, but yourquestions will all be answered. and some of the questions,again to remind everybody, these slides and mountainsof other material in many languages are availableat our web site. so i did get a whole bunch ofquestions regarding billing, and

i would like to say thatthat is unfortunately not the focus of our presentation. unfortunately, the billing worksare the individual work of your professional association, soi encourage you all to become members, if you are not already,of your association because that involves a differentlevel of government, cms. and what our goal here today isto really to teach us all to be better practitioners andmore caring practitioners within our community.

so, am i going to get paidto tell somebody that the right thing for them to dois to call the pharmacist? no, i am not. could i perhaps documenta higher level of visit if i am counseling the patient? that may be a possibility, buti am not going to break down ways to get paid, becausefrankly for a large part, there are not ways to get paid. it is the satisfactionof knowing that what

we are doing is the right thing,of becoming well known and well identified as caringpractitioners within our community. the way we will all benefitfrom this is that we will be identified as those people,and we will work with other groups within our community. you will have your ownreferral network within your community and buildyour own individual level of experience and care andreputation doing this.

dr. leal, we did have somebodyask about pharmacies--when patients use mail-awaypharmacies--how would they speak with a pharmacist? would you like toaddress that, please? dr. leal: yes, thank youvery much for the question. so, there are a couple of ways. you can definitely call the mailorder, but i think even just walking into a pharmacylocally, the pharmacists that i have worked with, andi historically worked in

a retail pharmacy myself,we are very willing to help patients who walk in, evenif they are not obtaining their medications at thepharmacy that we work at. so, that is one of thenice things about having an accessible provider thatis available to you nights, weekends, is that you can walkin and ask your questions and they would be willing to help,despite the fact that you don't go to their particularpharmacy to have your medications dispensed.

i do want to say though, ifthe patient were to bring their medications ortheir medication list, they would probably havea better interaction with the pharmacist, becausethey would know exactly what they are receiving, sothat would be something that i would recommend. but i think any pharmacist inany community setting would probably be willing tospeak to the patient. dr. frisch: thank you.

dr. la fontaine,we had a question regarding diabetic shoes. would you like todo a general comment regarding diabetic shoes? and somebody asked herespecifically how their foot related conditions arebeing or not being documented? dr. la fontaine: yes. so yes, the shoe bills from cms. you know, the requirement hasbeen changing over the years.

obviously it is acumbersome process, because the podiatrist is aprescribing physician--if you are prescribingto a medicare patient, the prescription needs to gotogether with a certification of primary care physicianthat is handling the diabetes for the patient. so for the patient toessentially get the shoes approved by medicare, one, hasto have certain risk factors. two, has to have a certifyingphysician stating that

the patient doeshave diabetes and does have those risk factors. and three, may need aprescription to make the shoes. now, one of the things thatwe have encountered in our hospital is that often wheneverwe said the patient has vascular disease,hammer toe, neuropathy, whatever the risk factor is,it needs to be documented on the patient’s chart, sothat note can accompany the prescriptionto get the shoes.

and yes, that is probablythe most difficult one to get because most of us practicein different locations, so you don’t have accessto the record of another doctor to include “yes, this patient has vasculardisease, or he has a bunion.” so yes, you may be able toget a patient, to get from the primary care physician, the certificationthat they have diabetes. and may also get it eitherfrom the certified physician or

the podiatrist to say, “yes, this patient has a bunionand all this too,” and then take that to theorthopedist or whoever is going to be making the shoe. so yes, the processis cumbersome. dr. frisch: so, a recap ofthat for everybody on the call, we all know that wehave patients come in and they are going to say, “my neighbor got freeshoes from medicare,

how do i get my freeshoes? i have diabetes.” it is not as simple asthat, and they do need to discuss this with theirpodiatrist or primary care provider or endocrinologist. there was a question fororal health here that says, “could you please explainin additional detail how the control ofperiodontal disease can lead to improved a1cand glycemic control?” ms. furnari: that seems tobe a very, very scientific

question, and i would behappy to refer the person who has asked thequestion to a study, which i apologize i do not haveat hand right now, but when we do answer all the questions,i’d be happy to refer the person to the study,with the results of that. dr. frisch: thank you, andi will also just add, and i am podiatrist, so not adental health care professional, but i can tell you that simpledentition changes the diet. so if people are not eatinghealthy foods because they

can’t chew them appropriatelyand they are eating high carb foods, softer foods,more prepared foods, it can be as simple as theirdentition, and so we prevent periodontal disease and helpthem keep their own teeth, it can be that simple. so, some questions,other general questions that people asked. “is the toolkitavailable in spanish?” yes, there are tons oflanguage products available.

another question was lowhealth care literacy materials. the answer is, yes, they areavailable and i will repeat what the opening comments were. none of these arecopyright protected; you can reproduce these, youcan put your own logo on them. this, honestly foreverybody on the call, is easier than you think. just be familiar with thematerials and take a moment to care, and you can call apharmacist and introduce them.

we did have a comment here thatwas very profound from somebody. i am trying to scroll toit so forgive me, but the gist of it was, it is betterto have a list of providers in your community, ratherthan simply saying “see a podiatrist” or“see an optometrist.” so, if you are anoptometrist and you work with a few pharmacies, it issimply a matter of saying, “if you need to have some ofyour patients who come in who have questionsregarding their diabetes,

i will be happy to see them.” it’s like startingyour practice over, when you knocked on doors and said, “i am new in town. here are some cards,please come see me.” well, now we arestarting a new program. we are starting aprogram to improve diabetes care in our community. and that’s the pebble in thepond, ripples that will grow.

you may reach out--as apodiatrist i’ve called several of the localoptometrists within a geographic range ofmy office--and ask if they have desire tosee diabetic patients. one of the other things that areavailable on the web site is a simple checklist for patientsthat they can actually fill in. it is a piece of paper, and youhand it to them and it says, “what was the lastdate i saw provider x?” or “when is my nextappointment?”

so they can keep this and putit in their little folder of health care informationand move forward. a question somebody has askedus about the prevalence of depression and anxiety iscommon, and does the team access the need for behavioralhealth services? these materials were all vettedthrough the behavioral health services, and it ismentioned throughout that it is an important factor in it. but the ppod team wasdeveloped simply as we began

the program, is veryoften, we as providers are the first line of people tosee somebody with diabetes, and you all see itevery day even more. if you’re asking somebodyto sign the keypad that they received their prescription, andthey are pulling out glasses or saying, “i can’t see the box,” you simply say “haveyou had a recent exam?” you just gave them theirmedication that you know they are diabetic.

if somebody comes in to havetheir teeth cleaned and they are wearing slippers, we know thatis an inappropriate behavior, so all we have to say is, “gee,ms. smith, i see you are in slippers today. issomething wrong?” there are hundreds ofsimple little moments, care moments, that wecan all give and become more excellent providers. sandra, we have a question here. “what recommendationsdo you have to improve

coordination ofreferrals to pharmacists? we have diabetes programs inplace, but it can be difficult to get physicians to see thevalue and refer their patients.” dr. leal: thank youfor the question. yes, it can be difficultdepending on the practice that you are at, butdefinitely marketing. i think you mentioned, dr.frisch, some of the things. just go out andintroduce yourselves. as a pharmacist, i workin a health system, and

we’ve built in some automaticreferral type of mechanisms within our electronichealth record, where one of the dropdowns for thereferrals that can trigger a visit to the pharmacist. so there are ways you cancreate that referral system. i think the other way isdefinitely marketing to the patients and having thepatients ask for referrals to see the pharmacist. there are other opportunitieswith medicare part d to do

medication review, and you canalso even have referrals from other pharmacists to be ableto refer to your program, especially if you arefinding that patients are having difficultycontrolling their diabetes. so really, looking at yoursystem and figuring out trigger points where youcould be able to remind people about the services you offer,making yourself available, and then just going out and likeyou said, knocking on doors and introducing your services andthen talking to patients about

self referrals are key ways toget those appointments filled. if there are more questions,please feel free to type them in your chat box, and we willcontinue to address them. so, here is onethat somebody asked. “what have been the biggest challenges in thetransformations?” and honestly, the biggestchallenge is inertia. it’s us taking a moment in abusy day to do one extra step. it’s nice to have the plugand play and have our own

electronic records dosome of the work, and it’s nice to hand out materials, but it does take alittle extra step. it doesn’t always haveto be you as a provider. sometimes it can be yourstaff, sometimes it can be, “please see the receptioniston check out, and she will print something out.” on our office web site, myown personal office web site, i simply have a referral page,and the referral page in

the back tells patientshow to access ndep. it also tells them how to go to smoking cessation classesand what have you. and i can simply tell them,“please access the web site, the information you need to goand get things is right there.” this toolkit right now thatwe are all talking about addresses us as providers. there are other patient-directedmaterials there as well. so that web site is avery vast--and you can

get lost sometimes within it. if you have an hour some day,spend some time because there are incrediblethings in there, even recipes and cookbook referrals. so please review it. somebody asked the questionabout a dsme program, and if you would clarify what you arespecifically wanting from that, i will be happy to refer youto our appropriate answer. so let’s see, what else doi have on my question list?

“how does a solo practitioner in practice over 25years implement this?” i think iaddressed some of that. it is just simply talking to thesources that you already use. at 25 years, you are theperson we want, because you already have your network,you already know who your key pharmacists are inyour area and your key optometrists andyour key dentists. if any of you are soinclined, your local county

dental society or optometrysociety, go and attend as an outside practitioner and say, “hey, i would like todo this with some people in my area, who is game?” these slides are available for you to downloadand take and present. remember, if you do that,as a podiatrist today, dr. la fontaine’s job was notto educate podiatrists about podiatry care--it was toteach the other providers

a little bit about what we do,and that is what each of our jobs were here withworking with you today. so let me see if i haveany other questions. seeing none popping rightup, i will turn it back to dr. allweiss for a wrap up. dr. allweiss: thank youdennis and everybody for participating andthe good questions. on the slide it says “ppod, howto get started, and that has the link to the materials.

you will find powerpointpresentations that you can send to providers. eventually, this willbe there as well. we have also havethings for consumers. as dennis mentioned, we have theone pager checklist on one side, and on the other side, wehave what kind of questions for all of the ppod providers,so it’s like a one stop. it’s a one-pager that you canjust download for your patients. we have that inenglish and in spanish.

we also haveone-pagers on each of the ppod specialtiesfor consumers. these have been screenedfor health literacy, simple language, and they arecalled “healthy eyes matter”; “healthy feet matter”;“know your medications.” basically, they are one-pageeducational tools that you can download and give to yourpatient, and it will tell them about why it is importantto take care of your eyes, your feet, your teeth, and alsohow to talk to the pharmacist.

so all of the tools are there,just go to that link, and you can find many of them aswell as other ndep products. we want people to shareconsistent messages, and we want people to know thatfolks should control their a1c, their blood pressure,their cholesterol, and they should not usetobacco products. these are all consistentmessages that we feel the primary care folks, aswell as ppod providers, can give to their patients.

team care involvesa lot of folks. ppod just happens to beone more organized group. somebody had sentus in a chat box, “are there any other examples?” and indeed, inmassachusetts there was a massachusetts ppod group, andwe even have some slides from presentations fromthem in the past. be sure you pay attention to the problems in yourother ppod areas.

as dennis said, if somebodycomes in to your office and you are a dentist, andthey are wearing slippers, that is a sign. just notice it and be sure thatyou ask the patient and the patient’s family, “has this person had any otherproblems with their feet?” or whatever. so, it is a team approach,and it is important to call. if you have a question, callthe primary care provider,

because they wantto hear from you. and so we want you tocollaborate with everybody: with the podiatrist, thepharmacist, the optometrist, the dentist, but also don’tforget about the primary care folks and nurse practitioners,the nutritionist as well, also community health workers. these folks canreally help you bring your message to your patients. and talk to your localassociations as dr. frisch said,

and the local chapter of thenational associations, so the optometry association, the podiatristspecialty organization. they are all in the community. tailor and useyour ppod materials. so certainly, if you are in youroffice, put your logo on it. these materialsare evidence based. they have been pilot tested. they are credible.

we are trying tomake your job easier. so if you need anymore information, please go to the ndep web site. i would like to thank ourpresenters, dr. frisch, for being the moderator;all of the participants. you can see the general ndepweb site, and if you do have any questions, please emailme and i will be forwarding the email to the specificspecialist who will be able to help you, and then wewill email you back an answer.

so thank you somuch for participating. everything will beposted on the web site (i think it was slide 44). it might take a couple of weekswhile we process everything, but everything will beon the web site. so thank you so muchfor participating in this team care webinar. dr. frisch: thank you everybodyand have a wonderful day, and please take an extramoment to care and help

stem the tide of diabetes.