Who are the Members of a Diabetic Management Team

Who are the key members of a patient's Diabetes management team? Larry Ellingson: If you go back, maybe 50 years ago, the team probably consisted of the rural GP or primary care doctor, the pharmacist, the druggist in the store, and maybe the distributor of the products in that community. Today it's much more complex. The pharmacist -- I put the patient at the center of all of this, because they really have to manage the disease much different than some of the other health diseases. The patients are really in-charge of this one. But the pharmacist is one member of the team that sees across all of the aspects, of the drugs that they are taking, the monitoring, the other medications. The diabetes nurse educator, the primary care physician could be the Endocrinologist, could be a cardiologist in some cases. You also have the podiatrist for foot care. You may have the ophthalmologist for eye exams, you may have psychologist for counseling and support, diabetes educator, nurse, dietician. So the team is much broader than before, and often times involves the insurance provider, the payer or the government in some cases. So the team is much larger than it was a year ago, which encourages us to think about how do we talk to each other. How do we get all this information, share it, communicate, and do the best we can for that patient. Richard Rubin: People with diabetes are the principal members of their diabetes care team. Of course they need support, they need professional help and advice and so the other key members are a physician, a diabetes educator who could be essential in helping that person, manage, make good decisions and stay up-to-date with things. And then of course some people with diabetes need other folks as well. You might need a podiatrist, if you have foot problems. You might need a mental health professional because mental health problems are more common in people with diabetes and when those problems are treated effectively, it makes a big difference, not only for how people deal emotionally, but how well they manage their diabetes too. And dieticians are very important, we talked about diet before, nutrition is such a critical part of diabetes management and nutrition is also an important part of the team. And last but not least at all is the pharmacist. Because the pharmacist is the person who has the most regular contact with the person who has diabetes. People go in to get their prescriptions filled on a regular basis. Pharmacists often know their patients quite well, so the pharmacist is also a key member of that diabetes health care team. What role does a trained pharmacist play? Larry Ellingson: I think the pharmacist is really at the front line of all of this activity, he is the one individual and he is often times the most accessible or seen the most frequently by a patient with diabetes or a patient with hypertension because he is in the drug store to pick up medication or other medication that they are using to manage their diseases. So the pharmacist can see if he is on blood sugar pills, if he is taking insulin, if he is using a monitor, if he has got hypertension, he has got cholesterol, if he has got weight challenges that he might or the family members have a concern there. So he is one of those people on the team that sees across the whole spectrum of activity, and he is in a good position to say, okay, I need to ask the patient about his blood sugar. Did he get his Hemoglobin A1c checked? What about his blood pressure? What about his cholesterol? Did he see his doctor? Did he get his foot/feet checked? When is his last eye exam? Lots of questions to get the pharmacist out behind the counter to talk to the patient and the family member about this disease. Richard Rubin: A trained pharmacist can play a whole lot of roles. Medication is a tremendously important part of the diabetes regimen. People who had diabetes, as people who have any other condition do not tend to take their medication exactly as prescribed for all sorts of reasons. The pharmacist is the point-person for finding out in a gentle way from the patients whether these medications are being taken as prescribed. For example, if the person comes in and hasn't refilled a prescription for a long-long time and the pharmacist knows, this is something that should be taken regularly, asking a little something about what's going on can be helpful? Kathryn Wesling: I mean, when we put in their prescription, it has the directions, we know how many we gave; we know how many days supply that should last. If you constantly have somebody coming and filling their prescriptions late, then the doctor writes a new prescription for a higher dose. It's kind of a piece of information. It needs to get back to the doctor, that do you really want to increase this dose or do we really want the patient to be more compliant. Larry Ellingson: What's their blood sugar? How's their hypertension? They have any blood pressure problems? Cholesterol. What kind of diet and exercise regimen are they on? Are they doing any? How frequently they monitor their blood sugar and test? And are they always going back to the primary care physician or their specialist for this? They should be tested quarterly, they should check in with their doctors once a quarter and get their hemoglobin A1c checked. They need to have their eyes checked at least twice a year. They need to have their feet examined on every visit for circulation and any infections that are tested. Kathryn Wesling: Maybe they are having side-effects that they didn't realize what the side-effect of the medication and we can give that information back to the doctor and having change the drug. It all works as a puzzle and we hope that by working as a team, they get all the pieces of the puzzle. Richard Rubin: Just checking with the patient on a regular basis when the patient comes in, how is the diabetes going? Anything what I can do to help? You can also be helpful. Pharmacist can play an important role because they are there, they know the patients' medications, and often they know the patients very well too. In many places, counseling, patient education is a part of what pharmacists are legally required to do, for patients who have chronic conditions. So this is a real opportunity for pharmacists. Kathryn Wesling: We may see if somebody comes in with their meter and we see, we can look at their memory and see that maybe their readings have been off for a while, you can kind of troubleshoot, it's always the warning doses. Well, then we need to -- their morning readings, well, maybe we need to change or make a recommendation for a change in their night-time med. So that it carries them over through the morning, or they could again be back to diet, maybe they are not eating breakfast or that type of thing, so then you can give that information back to the physician's office. Richard Rubin: I think that what pharmacists can and should do in many cases do, is check with the patient about any problems they are having with their medication, any side-effects that they might be having, any cost related difficulties, any confusion about the actual prescription for the medication. When should I take it? How should I take it? What are the conditions under which I should take that? If pharmacists do that kind of monitoring and checking, they are very likely to be able to help patients take their medication closer to the prescription and get the benefits of doing that. Kathryn Wesling: They may go to the physician once every three to six months. They are in here every month getting their prescriptions refilled or getting new strips for their meter, that type of thing, they walk in and immediately get service. Whereas you don't have to call ahead and get an appointment to see the doctor, and then we are able to provide them the information that they need through the fax or telephone back to the office. It's probably another piece of the puzzle they may not get from the patient. Richard Rubin: A lot of pharmacists act like they are so busy and they probably are so busy, they don't really want to talk to you. But in other places, pharmacists are really seeing this as an opportunity. In fact, it's really fascinating, pharmacists are the largest -- have the highest rate of growth of any profession within the American Association of Diabetes Educators. That segment of the AADE membership is going more rapidly than any other profession. The same within the American Diabetes Association. The same amongst certified diabetes educators and there are now as many pharmacists coming to the American Diabetes Association annual scientific sessions as nutritionists who come to those needs. Pharmacists are taking the larger and larger role in helping people manage their diabetes. One very good reason for that is, how many medications most people with diabetes take? There was a study that was recently done by a colleague of mine, that shows that the average person with diabetes takes seven different medications, having different medications a day including of these two blood group of medications, seven medications a day. The pharmacist is the one who knows those medications best, and who can be most helpful to the patient in seeing to that those medications are taken as prescribed and aren't causing any special problems for the patient. Are some pharmacists better trained in Diabetes than others? Larry Ellingson: The American Pharmacists Association, The National Community Pharmacists Association have advance training programs. And there is actually a certification examination for pharmacist and other specialties for a certified diabetes educator, meaning they've had training in the therapeutic areas, the diet, the nutrition, the exercise, across all components. And if you see a pharmacist that's got a RPH, PharmD or - and/or CDE behind their name, they have been certified as having Advanced Training in Diabetes. There are other pharmacists that have advanced training. Both by American Pharmacists Association and the National Community Pharmacists Association do advanced training. So there are many out there. We would encourage you to utilize those resources that have this advanced training and ask about it and talk to your pharmacist about these concerns. Richard Rubin: Certainly, if the pharmacist has a certification called Certified Diabetes Educator or CDE, that person is very highly-qualified. As I was just mentioning more-and-more pharmacists are getting this credential. It's a voluntary credential. It's a credential available to anyone who has substantial experience in diabetes education with patients and has taken out a certifying exam and he is a licensed healthcare professional. More-and-more pharmacists are doing this, and certainly any pharmacist who has gone through all that work and has gotten certified by the National Certification Board for Diabetes Educators, is a very highly-qualified person. Now there is still not that many pharmacists who have the CDE. So probably other ways to find out or just to talk to the pharmacist and see what the experience is, but a pharmacist with CDE is sure to be a highly-qualified person. Larry Ellingson: There are special credentials, I think for the certified diabetes educator, they have to have the number of hours in clinical training and passed an examination in these various components of the disease. Therapeutics, pharmacology, diet, nutrition, etcetera, that all relate to diabetes. What is the one thing diabetics should remember about managing their disease? Larry Ellingson: Patients with diabetes should recognize that the pharmacist is a resource in their community. That they can rely on who has trusted, he has been educated, he has been trained, he understands the disease, he understands the other medications in the diseases that you may have and that you should seek information from them and encourage the patient to ask the pharmacist questions and create a dialogue. So that he understands more about what you are doing? What medications you are taking? What other concerns you might have? And that your family also understands that he is a trusted resource in the community. So I encourage patients to reach out to this resource. He is one of many in the team, but he is one that you probably see most frequently. Richard Rubin: The pharmacist can be a very, very good resource for you in managing your diabetes, and especially in resolving any problems at all that you might have taken your medication. Most people with diabetes take lots of medications. Almost invariably those people have some kind of a problem with one or another with those medications. The pharmacist is the expert in these medications. It can really help you figure out what's the best thing for you to do, if you have any difficulties with your drugs. Kathryn Wesling: I want them to feel like they are living a normal life. Yes, they have diabetes but it's manageable. I don't want it to stop them from doing things. Don't feel like they are trapped in their house because they have to test their sugar so many times a day, or kids they can still have normal childhood, play sports, go stay at their friends' over the weekend and that kind of thing, they are not missing out on the things that we all enjoy that don't have diabetes.