I am Dr. Pam Allweiss, an endocrinologist with
the CDC Division of Diabetes Translation.
I would like to welcome you to this webinar.
Today PPOD is not a vegetable; it’s a wonderful team of
passionate providers who have come together to develop
materials and a webinar to illustrate how team care for
people with diabetes can become a reality.
They energize all of us, and we are trying to walk the walk when
it comes to team care.
You can see all of their bios on the screen.
PPOD providers may be the first person who
sees somebody with diabetes.
Our goal is to have team care on your radar screen.
We are not trying to make optometrists 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 for providers and for patients,
which have been pilot tested in many of our provider’s offices.
For instance, we have a patient checklist that has
been developed and evaluated by our PPOD providers,
as well as by primary care providers such as
family practice docs, nurse practitioners, etc.
Everything will be available on the Web site, including
the slides and the recording of this webinar.
At the end, we will answer general questions and,
eventually, all questions that you submit to us
will be answered.
I have two requests: Please stay connected at the end and
fill out the quick survey about today’s webinar, and then
please, please fill out the survey that will
arrive in your box in a few weeks to evaluate if there has
been any change in how you practice team care.
We really need the information to help us
evaluate what we are doing and to improve.
Now, I would like to turn it over to Dr. Dennis Frisch.
Thank you, Dennis.
Dr. Frisch: Thank you, and thank you, everybody,
for taking some time out of your day to learn about team care.
In this section, we are going to learn about the NDEP, which is
the National Diabetes Education Program, the scope of
diabetes in the U.S., and the PPOD team care approach:
what it is and why it’s important.
So, what is the NDEP?
The NDEP was established in 1997 as an initiative of the U.S.
Department of Health and Human Services.
It was established to promote early diagnosis of diabetes,
improve the management of the disease and its outcomes, and
prevent and delay the onset of type 2 diabetes.
The NDEP is jointly sponsored by the CDC and NIH.
NDEP brings together more than 200 federal, state, and
private sector agency partners.
We at the NDEP believe in the importance of
team care approach to diabetes.
A team approach among PPOD providers, as well as many other
health care professionals, is of crucial importance in
helping patients to maintain their diabetes and to take
the needed steps to lower the risk for complications,
including, in our particular case today, those related to
feet, eyes, teeth, and medication management.
Working Together to Manage Diabetes, a toolkit for
pharmacy, podiatry, optometry, and dentistry, offers
resources to support providers in this important work.
So, what is PPOD?
PPOD is a team approach among pharmacy, podiatry,
optometry, and dental providers, as well as other
health care professionals, and is of critical importance in
helping patients to manage their diabetes and take the needed
steps to lower the risk for complications, including those
related to our particular fields of feet, eyes, teeth, and
medication management.
PPOD providers are well positioned to deliver key
diabetes management and prevention messages, to
communicate the need for metabolic control, and
encourage patients with diabetes to see their
optometrist, podiatrist, and dentist at least
once a year and to review their medication therapy with
a pharmacist at least annually.
Our PPOD message emphasizes the importance of all health care
providers treating patients with diabetes.
PPOD providers have the opportunity to educate
patients with diabetes about their disease, to encourage them
to practice self-management, and
to provide appropriate treatment.
As we’ve discussed, diabetes is a serious problem that affects
many people each day in the U.S. and its territories.
Why is PPOD important?
PPOD makes a difference for patients with diabetes.
Not only can it provide treatment outcomes, but
it can also greatly enhance a patient’s treatment experience.
A team approach to diabetes care reduces risk factors,
it improves management of the disease, and it lowers
the risk for complications that can result from the disease.
PPOD providers are in a unique position to make a difference in
their patients’ lives, as they may often be the first
health care provider to see a patient experiencing
a new problem.
For example, a patient may complain of blurred vision at
a visit with his or her optometrist.
The patient may not realize that this can be a sign of diabetes,
allowing the optometrist an opportunity to ask other
questions about the patient’s condition.
As a part of a PPOD team, the optometrist will be aware of
the signs and symptoms of diabetes and can refer
the patient to his or her primary care provider to
seek further tests and/or treatment.
PPOD providers are in a unique position to identify signs and
symptoms that could otherwise be missed, and they may continue to
monitor a patient’s condition at routine checkups, such as
dental cleanings, dilated eye exams, and
annual podiatric exams.
Many patients turn to these professionals before consulting
primary care providers with common diabetes questions about
self-care or medications.
NDEP encourages all health care professionals to understand
their unique contribution to diabetes team care so
their advice to patients is consistent.
There are tremendous opportunities for getting
messages about diabetes control and prevention.
The team care approach has a number of benefits for patients.
A team approach among PPOD providers, as well as other
health care professionals, allows access to integrated
diabetes care across specialty and primary care areas.
A team care approach encourages regular communication among
a patient’s team of health care providers and emphasizes
the importance of prevention.
At this point, I’m going to turn it over to Sandra Leal, who is
going to speak to us about the role of pharmacists in PPOD.
Dr. Leal: Thank you very much
for the introduction, Dr. Frisch.
This is a pleasure to be here representing the pharmacist’s
role in diabetes management because of the importance that
pharmacists can have in really assisting patients to be
advocates for their own condition.
And so, a couple of really key points about
the role of the pharmacists.
They are a unique member of the healthcare team and oftentimes,
because patients are taking multiple medications for
diabetes and comorbidity, such as blood pressure issues or
cholesterol issues, they might be seeing their provider up to
seven times more often than other providers, so this offers
a unique opportunity for the pharmacists to be able to
intervene several times during the year, several times during
the month, even, if the patient is coming in to
the pharmacy on those occasions.
So, the pharmacist is often the most accessible health care
provider since there is no appointment required to see
the pharmacist, and pharmacists are also available
at all hours of the day.
There’s 24-hours pharmacies; they’re also available in the
weekends, and again, because there is no appointment needed,
the pharmacists can play a unique role in being able to
help the patient navigate through this condition.
Some of the roles that the pharmacists have really
taken--and the American Diabetes Association has promoted--is
the role of the pharmacist in monitoring
the drug medication regimen.
This is really, really key, because of all the opportunities
to help the patient work through their plan and be able to
better and more effectively use their medications.
The pharmacist may work with the patient to develop a plan that
reduces the side effects and drug interactions and really
advise a patient on how to take the medication properly.
The pharmacist may also help the patient with other things that
are very important to control, and one of the things that’s
very key are things around medication affordability.
With all the medications that a patient takes, sometimes this is
a key intervention that the pharmacist really takes
a lead on, and trying to help assist the patient in being
able to afford not only medications, but things like
testing supplies that they might need to better control
their medication regimen.
Another big key role that the pharmacist can play is
communicating with the health care team.
Sometimes the pharmacist is the one that contacts the provider
on behalf of the patient or encourages a patient to schedule
other appointments that might be necessary, like followup for
an eye exam or a foot exam, if the patient is communicating
some of these issues with the pharmacist.
Some of the key questions to ask your patients about medication
therapy management, as you are seeing a patient, and really
an opportunity to refer to the pharmacist, are related to
these questions that are listed below.
So, the patient should be referred to a pharmacist if
the answer to any of these questions are
“no” or “unsure.”
“Do you have a list of all your medications,
vitamins, and supplements?”
If you are seeing a patient and they don’t have
a good knowledge of what the medications are or
the indications for the medications, the pharmacist can
really work to help develop a medication list with
the patient that makes sense for them and is current and is
updated on a regular basis.
“Do you know the reasons why you take each medication?”
Again, the indication is very key.
Sometimes you’ll see a patient bringing bottles to
your appointments, and you’ll find that, you know,
you ask them, “Why are you taking this medication for?”
And they say, “Well, I’m not sure, the doctor prescribed that
for me, and I don’t really know what that’s for.”
So, that would be another key trigger to say,
“You know, this might be an opportunity for you to work with
your pharmacist to get more information about
why you’re taking medication.”
“Have you reported any side effects from
your medication to your pharmacist?”
Sometimes patients will report that they stopped
taking a medication or that it makes them have
bad side effects from it.
It’s another key to find alternatives for the patient
that’s necessary, or to work through some of the concerns
that they’re having.
“Do you have any difficulty affording
your medications and testing supplies?”
Again, very key with the population that we are serving,
especially because there are so many medications that
the patient might be taking, and the testing supplies might be
something that is actually preventing them from really
obtaining good control.
And another key question is, “Do you understand the importance of
timing your medication in relation to your meals?”
And I think this is even more important when
a person is on insulin.
Sometimes, they may be taking the insulin after they eat or
several minutes to hours before they eat, which might
be actually causing adverse events for them.
And a pharmacist can really be key in helping them understand
the timing of the meals, the importance of adherence to
the medication, and really understanding how
the medication regimen is working for them.
This is an example of PPOD in action, so if a patient comes
in--this is a 40-year-old woman who notices blurry vision and
asks her pharmacist about reading glasses.
The pharmacist discovers that the patient was diagnosed with
diabetes last year, but did not return for followup visit.
The pharmacist advises that changes in vision may be
a sign of diabetes and not a need for reading glasses.
And we see this quite a bit in practice, where patients are
looking for some readers.
They might be complaining of needing to go to the
ophthalmologist, when in reality the cause is
high blood sugar and, with better control, they could
actually avoid that tremendous cost of obtaining glasses that
might not work for them once their
blood sugar is in better control.
But this is an opportunity for the pharmacist to step in,
arrange a primary care visit or a visit with the
ophthalmologist, or both, and really help the patient be
an advocate for themselves and have better control.
So, pharmacists can also refer her to the NDEP Web site,
which is listed as www.cdc.gov/diabetes/ndep
for more materials.
But again, a lot of ways to intervene on multiple occasions
because of the multiple opportunities to see the
patient, and that would really serve the patient
a continuous and a consistent message as they have to
continue to navigate this chronic condition.
Thank you.
I will pass it down to Dr. Javier La Fontaine,
who is a podiatrist.
Thank you.
Dr. La Fontaine: Good afternoon to everybody.
One of the other key members of the team is
obviously the podiatrist.
Diabetes leads to 60 percent of the nontraumatic lower limb
amputations, and diabetes per se increases the chance of
amputation, as I just mentioned.
But fortunately, those patients with diabetes
who are involved in routine foot care will have
treatable foot care problems, and therefore
we could essentially increase prevention this way.
Ulcerations are very common; they lead to amputation.
Unfortunately, once we get these ulcers healed,
they often re-ulcerate.
Up to 80 percent of them will re-ulcerate in 12 months.
So this is an ongoing problem that we need to treat.
And we need to do aggressive prevention, and
the patient needs to be aware of this.
Successfully, if a patient is involved in a routine foot care
program, over 80 percent of these ulcers can be preventable,
and therefore we can decrease ulceration and amputations.
This is how an ulcer is going to look, and usually these
ulcers do come up in the bottom of the foot…
…because the main problem that people with diabetes get is what
we call the “critical triad,”
which is neuropathy, deformity, and trauma.
So, trying to identify these patients at risk will
decrease ulceration.
Neuropathy is the most important component that leads to
ulceration, so therefore that is the number one target that
we are actually trying to accomplish on prevention.
And obviously, blood flow is also 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 identify those patients with neuropathy.
That is what we can, as a PPOD member, podiatrists,
we can help you identify these patients with neuropathy,
vascular disease, and deformity.
You know neuropathy, like you probably all know, is
essentially the nerve damage that occurs in diabetes, but
often this patient is going to come in to your office and
they are just simply going to tell you,
“My feet are numb.”
They are going to have other symptoms 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 really sensitive to anything--to touch,
heat, cold--sometimes they do come up and tell you
“I do have numbness.”
You obviously don’t need to learn this, but once you refer
the patient to us and we are going to identify
this patient with neuropathy,
this is what we are going to do for the patient.
Just simply do tests.
We are going to feel for vibration, which is the fastest
sensation that disappears on patients with diabetes.
We do that with a tuning fork and we do touch with a filament,
which will help us identify those patients that are
lacking the touch sensation.
We are also going to screen for vascular disease.
So essentially, just like in this picture, it is going to
essentially show you how we palpate for the pulses, you know
the dorsal [inaudible] and the 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, these are some of the deformities
we are going to be able to identify for the patient, so:
bunion, thickened toenails, ingrown toenails, history of
amputation, toe deformities, etc.
Essentially, we can identify this and educate
the patient as well, and provide them appropriate shoes.
You can see on the picture on the top, identifies that
somebody with a bunion on the right 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 simple for the patients.
So, some of the questions that 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 a podiatrist at least once a year?
Do you know how diabetes can affect your feet, and
do you know how to check your feet every day?”
If you ask these three questions and they answer to you
“no” or “unsure, we can just make a simple
referral to the podiatrist, and we can take it from
there and educate the patient and categorize it and put it on
their risk level, and therefore continue the appropriate
referral for these patients.
Now, this is a laundry list.
You obviously don’t need to memorize this.
But if you want to ask these patients a little bit more about
their degree of neuropathy or vascular disease, then we can
ask them these questions, like:
“Are your feet numb?
Do you have burning pain sensation?
Are you sensitive to touch?”
A lot of the patients think that is normal for them,
since it has been happening for two, three years, so just
triggering them to think about some of these questions.
Then you will be able to further identify 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 download from the NDEP Web site and the
PPOD link, so this should be easy for you
to keep in your office.
Now, some of the questions you are going to get
from patients are “Why are my feet numb?”
And I just essentially gave you the answer, and
they are essentially having some symptoms of neuropathy.
“My legs hurt when I wake.
What could cause that?”
Or “My legs get tired very easily.”
Those are usually signs of neuropathy, or it can be
a sign of vascular disease, so again,
these questions are key for making the
proper referral for the patient.
“I have a callus on my foot, what should I do?”
Obviously, we don’t want the patient messing with it, so
maybe making the proper referral to the podiatrist,
that would be also an important 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 swelling can be due to neuropathy,
can be due to vascular disease,
but it could be many other problems
like kidney disease, liver disease, heart disease.
So, you know again, these are some of the questions that
you are going to get from the patient.
These are probably the most common ones
I see in my practice, so any of these questions should
trigger a proper referral to a PPOD or podiatrist.
Thank you, and I think I am going to leave you with
Paul Chous, which is the optometry part of
the PPOD team.
Dr. Chous: Well thank you very much; that was really
a fantastic presentation.
I’m going to talk a bit about eye health and
optometry’s role in that.
It remains a fact that diabetes is still the leading cause of
new blindness amongst working age Americans
less than 74 years old.
The estimates are somewhere between 15,000 and 25,000
Americans become blind, principally from
diabetic retinopathy, each year.
In addition, about 11 percent of adults with diabetes have
some form of vision impairment,
which ranges from mild to severe.
Now, it can be something as simple as an improper
glasses prescription, and in fact, the majority of
patients with vision that is subnormal in
the diabetes population can be corrected by having
an updated refraction done.
Many of the eye complications of diabetes, especially
diabetic retinopathy and glaucoma as well;
these are painless conditions and may cause few or no symptoms
until the eye disease has progressed to a stage where
treatment may be far less effective.
And this is really a key message for all of us PPOD providers:
good vision on an eye chart does not mean that
patients don’t have serious eye disease.
Patient surveys suggest that fear of losing vision concerns
people more than any other diabetes complication.
Health care providers need to be aware that the increased risk of
depression amongst those with vision loss is readily apparent
to those of us who provide their eye care.
Adults with loss of vision function are about 90 percent
more likely to have clinical depression than
those without vision loss.
In addition, these patients are at increased risk for falls that
result in fracture as well as, at some point,
requiring nursing home care.
Health care providers need to be aware that patients with loss of
vision from diabetes can often be helped by seeing eye care
providers who specialize in the prescription and dispensing of
low vision aids specifically designed and customized for
various degrees of visual impairment.
This is a whole separate subspecialty within
my profession, called low vision, helping people with
significant vision loss.
Let’s talk about annual eye exams for a moment.
People with diabetes can maintain optimal vision and
healthy eyes by having an annual comprehensive vision examination
that includes a dilated retinal examination.
With early intervention of retinopathy or other
serious ocular complications of diabetes,
such as glaucoma, are found.
Doctors of optometry routinely perform these tests and many
others, including sophisticated imaging of the retina on
our patients with diabetes and other health conditions.
We have a couple of images here, just depicting diabetic
retinopathy on the left, with dot and blot hemorrhages
throughout the retina, and to the right is an optical coherent
tomography scan, kind of an optical cross-section of
the retina, showing fluid edemas.
So this is a patient with diabetic macular edema.
Often these patients have good visual acuity.
More than 90 percent of vision loss caused by diabetes can be
avoided with good diabetes management, including
the ABCs of good diabetes care: good A1C,
good blood pressure, control of blood lipids, and avoidance of
smoking, and early detection and timely treatment.
It is really important to realize that eye disease
caused by diabetes is often associated with other
complications, including cardiovascular, podiatric, and
periodontal disease.
This fact really underscores the importance of
a collaborative team care approach.
The other things that are much more common in our patients with
diabetes are things like dry eye.
So if the other providers see patients that are complaining
that their vision is fluctuating constantly and
they have red eyes--a lot of patients with
diabetes have dry eye.
About twice as common in people with diabetes than
the rest of the population.
This is something that eye care providers can really
help them with, and it’s also a sign, oftentimes, of
autonomic neuropathy.
A lot of patients won’t have symptoms of dry eye,
their eyes will be red, but they’re not as symptomatic as
their nondiabetic counterparts would be.
Let’s look at some of the key questions we should
all be asking our patients about eye health.
By asking some of these simple questions, larger issues can be
uncovered that could be potential red flags for
good management of diabetes.
If patients are answering “no” or are unsure about the answers
to any of these questions, it is recommended that they be
referred to their optometrist to seek further care, counseling,
and, if necessary, treatment or referral for treatment.
In my experience, one of the key concepts that we all need to be
aware of, is that good vision, as I said, does not mean
there are no serious eye complications from diabetes.
I got diabetes when I was 5 years old.
I had perfect vision until I was 21.
I went in to see my optometrist, who saw bleeding in my eyes.
I got treatment.
I had perfect vision on the eye charts, but
vision-threatening eye disease.
I see patients all the time with severe, sight-threatening
diabetic retinopathy, as well as glaucoma that can rob them of
vision, who are able to read 20/20 or better on the eye chart
at the time they are diagnosed with their eye disease.
This is a reality that underscores the importance of
regular eye examinations, even in patients with
no visual problems.
Here’s a good example of PPOD in action.
In this example, there’s a situation in which
a PPOD provider uses a routine visit as a way to engage in
a broader dialogue with the patient, and in this
particular case, the patient’s daughter.
Having knowledge about diabetes and its risk factors,
the eye care professional knows the patient’s daughter is also
at increased risk for developing diabetes and is able to provide
the family with an NDEP brochure, and is able to
advise the patient’s daughter to make a followup appointment
with her own primary care physician to be
screened for diabetes.
Additionally, the optometrist knows that
diabetic retinopathy is present in one of five newly diagnosed
patients with type 2 diabetes.
That’s a profound statistic.
So, patients with type 1 diabetes don’t have retinopathy
at diagnosis; they have had the disease for
a relatively short period of time.
But we all know by the time a patient is diagnosed with
type 2 diabetes, they have had 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 refer patients for eye examinations,
even if their vision is fluctuating.
You want to wait on prescribing glasses for patients because
their hemoglobin A1C is high; these patients still need to be
evaluated for the presence of sight-threatening eye disease.
The other factor that is examined in this case is the
optometrist recommends that the daughter of the patient also get
an eye exam, because African Americans past the age of 40,
in particular, are at dramatically increased
risk for glaucoma, which is another leading cause of
blindness, especially among Black Americans.
Oral health and diabetes.
Even though oral health complications are very commonly
associated with diabetes, we can find that 85 percent of
patients with type 2 diabetes report they have not received
any information on the association between
diabetes and oral health.
In turn, this extends all the way into the
health care professional community.
Many health care providers have little to no training about
the oral, systemic health association.
Diabetes and periodontal disease is a two-way relationship.
Periodontal disease is a bacterial infection with
inflammatory complications.
That systemic inflammation signals increases in
blood sugar levels.
Also, like any other infection, it can impair the body’s ability
to process or to utilize insulin.
On the other hand, diabetes does not cause periodontal disease,
but it is a leading complication of diabetes.
Diabetes lowers the resistance to infection and greatly
increases a person’s susceptibility of
developing periodontitis.
In turn, that periodontal disease makes it more difficult
to control blood sugar levels, so it is a two-way relationship.
It’s certainly associated with the poor glycemic control.
In addition, tobacco use and poor nutrition are also
risk factors for compromised oral health.
PPOD providers can help change this.
As they collaborate with other members of this health care
team, we can reduce the rates of periodontal disease and
other oral health conditions.
Oral health exams.
Diabetes patients really should be encouraged to adhere to
annual oral examinations.
The recall interval for oral patients is really determined
specifically for each patient according to
his or her needs and risk assessment.
The management of periodontal disease in people with diabetes
can result in significant reduction in A1C numbers,
so people with diabetes really should be encouraged to have
perio disease treated to eliminate infection and for
the aid in metabolic control.
Dental visits can also be used as an opportunity to educate
patients and to begin a dialog with the low-risk patients in
order to prevent them from becoming high risk.
Dental professionals are also comfortable discussing the
relationship between oral health and nutrition.
These opportunities can also be used to affect the stem of
obesity and its relationship to diabetes.
Key questions to ask your patients about oral health.
People with diabetes are often not aware of the significance of
diabetes and poor health.
As I have stated, the health care provider whole entire
network does not seem to be very familiar with
the oral-systemic link.
By asking patients a few simple questions about their
oral health, larger issues may be uncovered that could be
potential red flags for the management of their diabetes.
If patients answer “no” or “unsure” about the answers to
any of these questions, it is recommended to please refer them
to their dental provider to seek further direction in care.
Ask them if they had visited their dental provider
within the last year.
Ask them if they know how important the relationship is
and how the effects can be in their mouth and if they really
do know the early signs of tooth, mouth, and gum problems.
Healthy teeth do matter.
So an example about PPOD in action.
Managing diabetes medications certainly can be complicated,
and it is also confusing for diabetes patients to understand
how to adjust their medication around certain events, such as
a dental procedure.
For a patient who has to have a dental procedure scheduled,
the dental professional might recognize that the patient is
really unsure how to manage their insulin injection, and
because she is told that before
the dental procedure she should not eat.
So to provide direction for the patient, the dental professional
arranges a pharmacy consultation for her to
resolve any unanswered questions and ensure that
the procedure does not interfere with her needed medications.
She can call the pharmacist.
The pharmacist can help her work around not eating and when
her insulin injection should be taken.
I have treated many patients with diabetes and have spoken to
other dental professionals who can attest to the fact
that many, many people out there need the intervention of
dentistry, along with the collaborative effect with
other health care providers.
Once again, healthy teeth do matter.
And I thank you and I take you back to Dr. Frisch.
Thank you everybody, and thank you for the presentations.
What we are going to do now, you have 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 is try to parse them out to the
different presenters and remind everybody that if
we don’t get to your question, we will answer them.
Over the next month or so, we are 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 your questions will all be answered.
And some of the questions, again to remind everybody,
these slides and mountains of other material in many
languages are available at our Web site.
So I did get a whole bunch of questions regarding billing, and
I would like to say that that is unfortunately not
the focus of our presentation.
Unfortunately, the billing works are the individual work of your
professional association, so I encourage you all to become
members, if you are not already, of your association because that
involves a different level of government, CMS.
And what our goal here today is to really to teach us all to be
better practitioners and more caring practitioners
within our community.
So, am I going to get paid to tell somebody that the
right thing for them to do is to call the pharmacist?
No, I am not.
Could I perhaps document a higher level of visit if
I am counseling the patient?
That may be a possibility, but I am not going to break down
ways to get paid, because frankly for a large part,
there are not ways to get paid.
It is the satisfaction of knowing that what
we are doing is the right thing, of becoming well known and
well identified as caring practitioners within
our community.
The way we will all benefit from this is that we will be
identified as those people, and we will work with other
groups within our community.
You will have your own referral network within
your community and build your own individual level of
experience and care and reputation doing this.
Dr. Leal, we did have somebody ask about pharmacies--when
patients use mail-away pharmacies--how would
they speak with a pharmacist?
Would you like to address that, please?
Dr. Leal: Yes, thank you very much for the question.
So, there are a couple of ways.
You can definitely call the mail order, but I think even just
walking into a pharmacy locally, the pharmacists that
I have worked with, and I historically worked in
a retail pharmacy myself, we are very willing to help
patients who walk in, even if they are not obtaining
their medications at the pharmacy that we work at.
So, that is one of the nice things about having
an accessible provider that is available to you nights,
weekends, is that you can walk in and ask your questions and
they would be willing to help, despite the fact that you don't
go to their particular pharmacy to have
your medications dispensed.
I do want to say though, if the patient were to bring
their medications or their medication list,
they would probably have a better interaction with
the pharmacist, because they would know exactly what
they are receiving, so that would be something
that I would recommend.
But I think any pharmacist in any community setting would
probably be willing to speak to the patient.
Dr. Frisch: Thank you.
Dr. La Fontaine, we had a question
regarding diabetic shoes.
Would you like to do a general comment
regarding diabetic shoes?
And somebody asked here specifically how their
foot related conditions are being or not being documented?
Dr. La Fontaine: Yes.
So yes, the shoe bills from CMS.
You know, the requirement has been changing over the years.
Obviously it is a cumbersome process, because
the podiatrist is a prescribing physician--if
you are prescribing to a Medicare patient,
the prescription needs to go together with a certification of
primary care physician that is handling
the diabetes for the patient.
So for the patient to essentially get the shoes
approved by Medicare, one, has to have certain risk factors.
Two, has to have a certifying physician stating that
the patient does have diabetes and
does have those risk factors.
And three, may need a prescription to make the shoes.
Now, one of the things that we have encountered in our
hospital is that often whenever we said the patient has
vascular disease, hammer toe, neuropathy,
whatever the risk factor is, it needs to be documented on
the patient’s chart, so that note can accompany
the prescription to get the shoes.
And yes, that is probably the most difficult one to get
because most of us practice in different locations, so
you don’t have access to the record of
another doctor to include
“Yes, this patient has vascular disease, or he has a bunion.”
So yes, you may be able to get a patient, to get from
the primary care physician,
the certification that they have diabetes.
And may also get it either from the certified physician or
the podiatrist to say,
“Yes, this patient has a bunion and all this too,” and then
take that to the orthopedist or whoever is
going to be making the shoe.
So yes, the process is cumbersome.
Dr. Frisch: So, a recap of that for everybody on the call,
we all know that we have patients come in and
they are going to say,
“My neighbor got free shoes from Medicare,
how do I get my free shoes? I have diabetes.”
It is not as simple as that, and they do need to
discuss this with their podiatrist or primary care
provider or endocrinologist.
There was a question for oral health here that says,
“Could you please explain in additional detail
how the control of periodontal disease can
lead to improved A1C and glycemic control?”
Ms. Furnari: That seems to be a very, very scientific
question, and I would be happy to refer the person
who has asked the question to a study, which
I apologize I do not have at 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, and I will also just add, and
I am podiatrist, so not a dental health care professional,
but I can tell you that simple dentition changes the diet.
So if people are not eating healthy foods because they
can’t chew them appropriately and they are eating high carb
foods, softer foods, more prepared foods,
it can be as simple as their dentition, and so we prevent
periodontal disease and help them keep their own teeth,
it can be that simple.
So, some questions, other general questions
that people asked.
“Is the toolkit available in Spanish?”
Yes, there are tons of language products available.
Another question was low health care literacy materials.
The answer is, yes, they are available and I will repeat
what the opening comments were.
None of these are copyright protected;
you can reproduce these, you can put your own logo on them.
This, honestly for everybody on the call, is
easier than you think.
Just be familiar with the materials and take a moment
to care, and you can call a pharmacist and introduce them.
We did have a comment here that was very profound from somebody.
I am trying to scroll to it so forgive me, but the
gist of it was, it is better to have a list of providers in
your community, rather than simply saying
“See a podiatrist” or “See an optometrist.”
So, if you are an optometrist and you work with
a few pharmacies, it is simply a matter of saying,
“If you need to have some of your patients who come in
who have questions regarding their diabetes,
I will be happy to see them.”
It’s like starting your 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 are starting a new program.
We are starting a program to improve
diabetes care in our community.
And that’s the pebble in the pond, ripples that will grow.
You may reach out--as a podiatrist I’ve called
several of the local optometrists within
a geographic range of my office--and ask if
they have desire to see diabetic patients.
One of the other things that are available on the Web site is
a simple checklist for patients that they can actually fill in.
It is a piece of paper, and you hand it to them and it says,
“What was the last date I saw provider X?”
Or “When is my next appointment?”
So they can keep this and put it in their little folder of
health care information and move forward.
A question somebody has asked us about the prevalence of
depression and anxiety is common, and does the team access
the need for behavioral health services?
These materials were all vetted through the behavioral health
services, and it is mentioned throughout that
it is an important factor in it.
But the PPOD team was developed simply as we began
the program, is very often, we as providers are
the first line of people to see somebody with diabetes, and
you all see it every day even more.
If you’re asking somebody to sign the keypad that they
received their prescription, and they are pulling out glasses or
saying, “I can’t see the box,”
you simply say “Have you had a recent exam?”
You just gave them their medication that you know
they are diabetic.
If somebody comes in to have their teeth cleaned and they are
wearing slippers, we know that is an inappropriate behavior,
so all we have to say is, “Gee, Ms. Smith, I see you are in
slippers today. Is something wrong?”
There are hundreds of simple little moments,
care moments, that we can all give and become
more excellent providers.
Sandra, we have a question here.
“What recommendations do you have to improve
coordination of referrals to pharmacists?
We have diabetes programs in place, but it can be difficult
to get physicians to see the value and refer their patients.”
Dr. Leal: Thank you for the question.
Yes, it can be difficult depending on the practice
that you are at, but definitely marketing.
I think you mentioned, Dr. Frisch, some of the things.
Just go out and introduce yourselves.
As a pharmacist, I work in a health system, and
we’ve built in some automatic referral type of mechanisms
within our electronic health record, where one of
the dropdowns for the referrals that can trigger
a visit to the pharmacist.
So there are ways you can create that referral system.
I think the other way is definitely marketing to
the patients and having the patients ask for referrals
to see the pharmacist.
There are other opportunities with Medicare Part D to do
medication review, and you can also even have referrals from
other pharmacists to be able to refer to your program,
especially if you are finding that patients are
having difficulty controlling their diabetes.
So really, looking at your system and figuring out
trigger points where you could be able to remind people
about the services you offer, making yourself available, and
then just going out and like you said, knocking on doors and
introducing your services and then talking to patients about
self referrals are key ways to get those appointments filled.
Dr. Frisch: Thank you.
If there are more questions, please feel free to type them in
your chat box, and we will continue to address them.
So, here is one that somebody asked.
“What have been the biggest
challenges in the transformations?”
And honestly, the biggest challenge is inertia.
It’s us taking a moment in a busy day to do one extra step.
It’s nice to have the plug and play and have our own
electronic records do some of the work, and
it’s nice to hand out materials,
but it does take a little extra step.
It doesn’t always have to be you as a provider.
Sometimes it can be your staff, sometimes it can be,
“Please see the receptionist on check out, and
she will print something out.”
On our office Web site, my own personal office Web site,
I simply have a referral page, and the referral page in
the back tells patients how to access NDEP.
It also tells them how to go to
smoking cessation classes and what have you.
And I can simply tell them, “Please access the Web site,
the information you need to go and get things is right there.”
This toolkit right now that we are all talking about
addresses us as providers.
There are other patient-directed materials there as well.
So that Web site is a very vast--and you can
get lost sometimes within it.
If you have an hour some day, spend some time because
there are incredible things in there, even
recipes and cookbook referrals.
So please review it.
Somebody asked the question about a DSME program, and if
you would clarify what you are specifically wanting from that,
I will be happy to refer you to our appropriate answer.
So let’s see, what else do I have on my question list?
“How does a solo practitioner
in practice over 25 years implement this?”
I think I addressed some of that.
It is just simply talking to the sources that you already use.
At 25 years, you are the person we want, because you
already have your network, you already know who your key
pharmacists are in your area and your
key optometrists and your key dentists.
If any of you are so inclined, your local county
dental society or optometry society, go and attend as
an outside practitioner and say,
“Hey, I would like to do this with some people
in my area, who is game?”
These slides are available for
you to download and take and present.
Remember, if you do that, as a podiatrist today,
Dr. La Fontaine’s job was not to educate podiatrists about
podiatry care--it was to teach the other providers
a little bit about what we do, and that is what each of our
jobs were here with working with you today.
So let me see if I have any other questions.
Seeing none popping right up, I will turn it back to
Dr. Allweiss for a wrap up.
Dr. Allweiss: Thank you Dennis and everybody for
participating and the good questions.
On the slide it says “PPOD, how to get started, and that has
the link to the materials.
You will find PowerPoint presentations that
you can send to providers.
Eventually, this will be there as well.
We have also have things for consumers.
As Dennis mentioned, we have the one pager checklist on one side,
and on the other side, we have what kind of questions
for all of the PPOD providers, so it’s like a one stop.
It’s a one-pager that you can just download for your patients.
We have that in English and in Spanish.
We also have one-pagers on each of
the PPOD specialties for consumers.
These have been screened for health literacy, simple
language, and they are called “Healthy Eyes Matter”;
“Healthy Feet Matter”; “Know Your Medications.”
Basically, they are one-page educational tools that you can
download and give to your patient, and it will tell
them about why it is important to take care of your eyes,
your feet, your teeth, and also how to talk to the pharmacist.
So all of the tools are there, just go to that link, and
you can find many of them as well as other NDEP products.
We want people to share consistent messages, and
we want people to know that folks should control their A1C,
their blood pressure, their cholesterol, and
they should not use tobacco products.
These are all consistent messages that we feel
the primary care folks, as well as PPOD providers,
can give to their patients.
Team care involves a lot of folks.
PPOD just happens to be one more organized group.
Somebody had sent us in a chat box,
“Are there any other examples?”
And indeed, in Massachusetts there was
a Massachusetts PPOD group, and we even have some slides from
presentations from them in the past.
Be sure you pay attention to
the problems in your other PPOD areas.
As Dennis said, if somebody comes in to your office and
you are a dentist, and they are wearing slippers,
that is a sign.
Just notice it and be sure that you ask the patient and
the patient’s family,
“Has this person had any other problems with their feet?”
or whatever.
So, it is a team approach, and it is important to call.
If you have a question, call the primary care provider,
because they want to hear from you.
And so we want you to collaborate with everybody:
with the podiatrist, the pharmacist, the optometrist,
the dentist, but also don’t forget about the primary care
folks and nurse practitioners, the nutritionist as well,
also community health workers.
These folks can really help you bring
your message to your patients.
And talk to your local associations as Dr. Frisch said,
and the local chapter of the national associations,
so the optometry association,
the podiatrist specialty organization.
They are all in the community.
Tailor and use your PPOD materials.
So certainly, if you are in your office, put your logo on it.
These materials are evidence based.
They have been pilot tested.
They are credible.
We are trying to make your job easier.
So if you need any more information,
please go to the NDEP Web site.
I would like to thank our presenters, Dr. Frisch,
for being the moderator; all of the participants.
You can see the general NDEP Web site, and if you do have
any questions, please email me and I will be forwarding
the email to the specific specialist who will be
able to help you, and then we will email you back an answer.
So thank you so much for participating.
Everything will be posted on the Web site
(I think it was slide 44).
It might take a couple of weeks while we process everything, but
everything will be on the Web site.
So thank you so much for participating in
this team care webinar.
Dr. Frisch: Thank you everybody and have a wonderful day, and
please take an extra moment to care and help
stem the tide of diabetes.
Thank you.