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Strategies to Help People with Type 2 Diabetes Start and Stick to Their Diabetes Medications
Credentials:
BSN
Clinical Health Coach
Certified Application Counselor
(Current student:MSN‐Informatics)
Contact:
Work Setting:
Linn County Public Health
Credentials:
Masters of Nursing in Health
Advocacy
Certified Medical Surgical
Registered Nurse
Certified Diabetes Educator
Contact:
Work Setting:
UnityPoint Health (Cedar Rapids, Iowa):
Combined Inpatient Glycemic
Management and Outpatient Educator
Non‐UnityPoint Affiliated:
Type2andYou.org
Type2andYou with Meg
(a diabetes podcast)
Megan Muñoz
Self‐Managed Stockholder in Tandem and Dexcom
Cindy Fiester
None
Identify the depth of the medication adherence problem in T2D
Identify barriers to med adherence in T2D Identify at least two techniques that can be applied to practice to improve medication adherence
Identify at least one resource that can impact medication adherence outcomes
Cost is a major, recognized barrier for medication adherence for patients. However, this presentation is focused on adherence techniques assuming cost has been addressed.
I knowwww…it’s hard after lunch!
American Diabetes Association (2019). Overcoming Therapeutic Inertia: Summary of Proceedings. Retrieved from https://professional.diabetes.org/sites/professional.diabetes.org/files/media/ada_therapeutic_inertia_interior_final.pdfEdelman, Steven V. and Polonsky, William H. Type 2 Diabetes in the Real World: The Elusive Nature of Glycemic Control.Diabetes Care 2017 Nov; 40(11): 1425‐1432.https://doi.org/10.2337/dc16‐1974
Most Common Patient Reported Barriers:
Diabetes Burnout
Forgetting Medication Doses
Not Seeing Immediate Benefit in Blood Sugars
Brand Name is Perceived as More Effective than Generic
Concern for side effects
Nelson, L. A., Wallston, K. A., Kripalani, S., LeStourgeon, L. M., Williamson, S. E., & Mayberry, L. S. (2018). Assessing barriers to diabetes medication adherence using the Information‐Motivation‐Behavioral skills model.Diabetes research and clinical practice, 142, 374–384. doi:10.1016/j.diabres.2018.05.046Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?.Mayo Clinic proceedings, 86(4), 304–314. doi:10.4065/mcp.2010.0575
Medication Management and Safety Assessments
Linn County State Innovation Model Grant 2016‐19
Number of Respondents = 57
Hospital (n = 30), Primary Care Clinic (n = 19), FQHC (n = 18), Public Health, Free Clinic, Diabetes Center, Specialty Clinic, Pharmacy
Provider, Nurse, Care Coordinator, Educator or Health Coach, Pharmacist/Resident, Social Worker, CEO, Clinical Manager
A majority of participants (87.7%) state that their organization does provide medication education Most commonly believed to be provided by provider, nurse, or pharmacist. However, no clear staff role responsible or protocol established for providing education
Typically 2‐5 minutes is spent on education. Time constraint played a significant role for 59.7% of respondents
Teach‐back was the most common strategy for ensuring patient understanding (64.9%) 75% of Providers note that they “Always” or “Usually” use teach‐back
12%
23%
28%
14%
4%
19%
0%
5%
10%
15%
20%
25%
30%
Very Good Good Acceptable Poor Very Poor Does Not Apply
A majority of respondents state that their organization does not have a protocol or process in place to confirm medication adherence (52.6%); an additional 19.3% of respondents were not sure if their organization had a protocol in place.
Personal processes Ask at appointment (56.9%)
Pharmacy Verification (39.2%)
Involve other members of care team (11.8%)
Discuss barriers with individual (9.8%)
Contact patient (9.8%)
12.5%
12.5%
20.8%
25.0%
29.2%
0% 5% 10% 15% 20% 25% 30% 35%
Med Syn programs
Medication Delivery
Med Pack programs
Private Counseling
Automatic refills
A majority of respondents (77.8%) state that they regularly ask patients about external barriers to taking their medications.
Care Coordinator, Social Worker, Health Coach: 87.5%
Providers: 82.1%
Nurses: 66.7%
SOCIAL DETERMINANTS
Cost (n = 41; 75.9%) Uninsured/Underinsured
Lack of Available Finances
Competing Priorities Social Stressors
Basic Needs (ex: Housing, food, bills)
Transportation EIHC and Hospital patients
particularly
OTHER
Misunderstanding (n = 23; 42.6%) When to start meds
How often meds need to be taken
Purpose and importance of taking meds
Possible side effects
Lack of Motivation Forget to take medications
ANCILLARY REFERRALS
Process for referral differed between organizations and at times respondents in same organization Respondents associated with
EIHC were most likely to agree on a specific process for referral; including staff responsible for handling
TRIGGER TO DIABETES EDUCATION
3.5%
7.0%
7.0%
8.8%
56.1%
61.4%
75.4%
84.2%
0% 20% 40% 60% 80% 100%
Physician Discretion
Patient Requests Referral
Does not apply
Lack of Achievement
Change in health status
Lack of Engagement/Compliance
A1C
New Diagnosis
Identify staff person responsible for providing medication education
Educate staff on agency practices and protocols Formalize and improve the process for, Providing medication education
Tracking and identifying medication adherence
Referring patients to external resources including diabetes education
Communicating patient information between discharging hospital and clinics (particularly for those without interfacing software)
March 2018
Routine and Organization Helpful Opportunity: Med Pack
program Misunderstanding of
Medications Side Effects* Dosage* Timing* Storage Importance and purpose* Stop when feel better* Change dose when feel
needed*
Communication Poor or no instruction on
taking med. Providers do not listen Providers and clinics do
not communicate with one another▪ Medication changes not
communicated following discharge
▪ Inaccurate medication list at different providers
Medication Barriers Cost*
Transportation*
Rural locale
Physical Limitations
Pharmacy▪ Refills delayed
▪ Different refill schedules▪ Opportunity: Med Sync and Medication DeliveryPrograms
▪ Price differences between pharmacies
Care Coordination Care coordinator or advocate assists with barriers, improving medication understanding and adherence
Want care coordination system
We get it, Megan and Cindy….it’s a problem. But what do we do??
Help Decrease the Diabetes Self‐Care Burden
PWD is ABLE to Make an Informed Decision vs an Emotional Decision
PWD Feels of Equal Importance on Their Healthcare Team
Understanding PWD Perspectives
Trialing Interventions
Changing the Narrative
NO ONE says
“Sign me up for a new kidney and a fake leg….”
Cost
Potential SE
Timing
He got off all meds. But it’s not working for me. What am I doing wrong??
• She takes insulin. She should’ve taken better care of herself. I would never let myself get that bad.
PWD‐Perceived “Success”
Weight loss
Little to no need for medication
Any medication use other than insulin
Science‐Based Reality Sustained weight loss near 2‐5% success rate
Only about 15% manage diabetes w/omedication
Healthy BG, BP, and Cholesterol lead to great outcomes regardless of medication type or body size
CDC. (https://www.cdc.gov/diabetes/statistics/meduse/fig3.htm
Our Language Has Lasting Impacts…
We Don’t Give Credit Where Credit is Due…Pulmonary HTN
Asked to Quit Work
Shame and Guilt around using state‐funded assistance
Using Regular Insulin OTC
Regular Hypoglycemia
Hasn’t seen PCP for 10+ years
Forced to Move in With Mom
Cardiomyopathy
Distrust of Medical System
Life expectancy 6 months‐1 year
Pick Up Insulin From Pharmacy
Pay out of Pocket for Insulin
Take Time to Take Insulin Doses
Check Glucose Levels
Continue Despite the Negative Impacts of Hypoglycemia
Understanding PWD Perspectives
Trialing Interventions
Changing the Narrative
We are theirhealthcare team.
They are not our patient.
Affective empathy and partnership have the two largest impacts on patient adherence. Ranking higher even than expertise….
“empathy …is of unquestionable importance”
No thank you… put those glasses back up and pat my back!
Kim, S. S., Kaplowitz, S., & Johnston, M. V. (2004). The Effects of Physician Empathy on Patient Satisfaction and Compliance. Evaluation & the Health Professions, 27(3), 237–251.
LISTENING IS KEY
“How well do you think your diabetes plan is working?”
“Tell me your biggest concern about your diabetes plan right
now.”
“Have you had to stop your medications for any reason?”
“Many people struggle with taking their medications, how often do
you miss doses?”
“Are you noticing side effects of your medications?”
Roadblocks/Resistance
Refuse initiation of insulin or other new medications Can’t take more than “X” units of insulin without
having a low blood sugar Going to start lifestyle changes “soon” aka a diet
program next month, gym next week, etc. Want to try lifestyle changes for longer before meds Don’t feel any different (not checking glucose) know
how their body “feels” with blood sugars and it “feels” fine
Diabetes denial Diabetes burnout
“I know you’d like to wait on medications until you start your weight loss program next month, but your blood sugars are too unhealthy to wait. We can always decrease or stop medications as your body changes.”
“Your A1c is at an unhealthy level. I’d like to talk through some options on how we can start getting your blood sugar into healthier ranges.”
“Your body isn’t the same at 60 as it is at 20, so it would be unrealistic if we expected your diabetes needs to stay the same too.”
Understanding PWD Perspectives
Trialing Interventions
Changing the Narrative
1. Demonstrate a Need/Make It Visible2. Maximize Current Regimen3. Explore New Med Options Together4. Trialing Technique5. Maximize Glucose Checking6. DSMT
Review their medical “evidence” WITH them:
Blood glucose logs
Labs
▪ A1c trends
▪ Kidney function
▪ Cholesterol
BP
Link reported med adherence to outcomes (without shaming them)
Their medical “evidence” is used to reinforce their view that plan is working OR help them identify a need for new one…
The Metformin Struggle…
How much could you impact
someone’s A1C level by showing them their lab result and
discussing it with them?
Chapin, R. B., Williams, D. C., & Adair, R. F. (2003). Diabetes control improved when inner‐city patients received graphic feedback about glycosylated hemoglobin levels. Journal of general internal medicine, 18(2), 120–124. doi:10.1046/j.1525‐1497.2003.20367.x
Extended Release/Long Half‐Life Meds‐20‐30%
Combination Meds‐26% Medication Pocketcards(FREE): https://diabetesed.net/pocket‐cards‐insulin‐and‐diabetes‐medication/
Extend this to HTN https://www.aafp.org/afp/2000/0515/p3049.html
Co‐pay Cards, Prescription Ass. Programs
Blister Packaging 90 Day Supply
Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?.Mayo Clinic proceedings, 86(4), 304–314. doi:10.4065/mcp.2010.0575KripalaniS, Yao X, Haynes RB. Interventions to Enhance Medication Adherence in Chronic Medical Conditions: A Systematic Review. Arch Intern Med. 2007;167(6):540–549. doi:10.1001/archinte.167.6.540
New Regimen:
Metformin ER 2000 mg daily
GLP‐1/Insulin Combo (Xultophy or Soliqua)
Current Regimen:
Glimepiride 2 mg/daily
Metformin 1000 mg BID
Victoza 1.2 mg/day
Tresiba 18 units/day
Explore New Medication Options Together
What does the conversation look like? Other health conditions (cardiac, renal, diabetes complications)
Age/#of Meds/Length of Time You’ve Had Diabetes
A1c
Use Medication Sheets and/or Discuss Risk/Benefits of Top 2
Verify insurance coverage/cost of the top 2 patient & provider preferred choices
1. The Trialing Technique
1. Maximize Glucose Checking
2. Follow‐Up/Review Patient‐Gathered Evidence
2. Diabetes Self‐Management Training
It’s Working SMARTER
Not HARDER
Trialing is effective because it turns: Long‐term into short‐term
Allows for medication or lifestyle “failure” without guilt
Sets up opportunity for patient‐identified success
Gives PWD room to move through guilt, fear, uncertainty
Allows you to troubleshoot any barriers to adherence (cost, pain on injection, s/e)
Sets realistic expectations
Ask if they’d be willing to trial the medication for “X” amount of time and come back to see you.
The BadThe Good
Discuss important aspects:
How to use and store medication
Potential side effects/benefits
When to expect blood sugars to be impacted
(Use Medication Sheet here or any visual/discussion that helps them better understand what to expect)
Glucose Checking Have them check glucose at times blood sugar will be most impacted
TIP:
Have them check at times blood sugars will be mostly affected for three days without meds and then do it three days when med has taken
near‐max effect
Example A: Traditional
Example B: Targeted
Fasting Post Breakfast
Pre Lunch PreSupper
Bedtime
204 400 300
222 280
156
Fasting Post Breakfast
Pre Lunch PreSupper
Bedtime
204 400
222 389
189 153
200 210
MOST people will come back with improved glucose levels or improved level of engagement when doing this form of checking
MOST people will extend the med adherence behavior into other times of the day
Can be applied to ANY self‐care behavior
Create a Follow Up Plan
Bring back their gathered evidence
Schedule when medication will be effective
Stay True to Your Word: Good, Bad, and…
What do you think? How did it go? What worked, what didn’t work?
Reinforce positive behaviors and support making invisible ‐‐‐‐‐VISIBLE (use patient‐gathered data)
Intervene on barriers to continued use of medication‐‐DSMT
Is A Process NOT an Event
POOF!
The things they feared are not so bad (ex: an injection)
Benefit outweighs the burden They can finally reduce stress about blood sugars (they see healthier ones!)
Improved quality of life
Less burnout
More likely to be active in their other diabetes cares
What if PWD always wants to put off med start until next visit because they want to continue working on diet and exercise?
Can’t take more than x units at meal?
WhatIfThey Come Back and Still Say “NO!”
Realistic expectations (75% in range)—remove “perfection” expectations
Risk vs benefit (not maximizing cost of med etc)
Dosing rapid with largest meal only
DexcomG6 alarms
Melanie J. Davies et al. Dia Care 2018;41:2669-2701
©2018 by American Diabetes Association
Lowers A1c1‐2%
ReducedHealthcarecosts More
likely tomeetself‐caregoals
ReducedHospitalizations/ER visits
Improved BP and lipids
Lower BMI
Improvementsin depression
Melanie J. Davies et al. Dia Care 2018;41:2669-2701©2018 by American Diabetes Association
Medication Makeovers
At minimum on an annual basis, or anytime a new med is added, review meds to see if any:
‐can be combined together‐can be switched to extended release‐can be timed differently to reduce the number of times a day they need to be taken‐can be reduced or stopped‐interact with one another‐are available in generic versions‐if the brand name medications have a copay card (discount card) that can be applied