Kathleen M. Dailey, MS, ARNP

With the Affordable Care Act’s expansion of health care coverage and the shortage of primary medical homes, outcome-based chronic disease management requires an innovative approach

There may be hesitation to treat chronic conditions such as diabetes in the retail setting. This article is intended to provide practitioners with background information and practical advice to assuage their fears as they move into new territory.

In its early beginnings, the retail health care (RHC) model comprised conveniently located clinics in a retail setting that offered a limited scope of services to treat common acute illnesses. These clinics were initially run by highly qualified board-certified family nurse practitioners (FNPs), but years later, went on to include equally qualified physician assistants.

Characteristics of the RHC model stem from its original purpose: to provide access to quality care at an affordable price that is available when needed. The types of clinical services provided in the retail setting have gradually expanded; once limited to treating common acute episodic illnesses and providing immunizations and camp physicals, retail clinics now offer an array of other services such as wellness visits; various types of physicals, including certified Department of Transportation exams; blood pressure screenings; medication refill visits; smoking cessation; weight management; and chronic disease management.

Over the past 15 years, the RHC model has evolved to that of a “partner” within medical communities, and in that partnership, convenient care providers are well suited to help medical home providers manage chronic diseases. One of the increasing challenges in primary care today is the diagnosis and management of diabetes. The Centers for Disease Control and Prevention estimates that 29.1 million Americans of all ages are living with diabetes.

It’s also estimated that 86 million Americans are at high risk or already have prediabetes, a trend that could mean that by 2025, 1 in 5 Americans could have diabetes, and by 2050, 1 in 3.

RHC clinics are positioned right in the communities where patients live. They are the places where patients see their trusted pharmacists for help with selecting safe OTC medications and for filling their prescriptions.

Diabetes in Retail: Diving into New Waters

Co-management of patients with diabetes in the RHC setting will involve specific considerations for different providers. For those who have worked within a limited scope of services for a vast number of years, a refresher course in diabetes management will ensure that quality care is delivered; the more knowledgeable the providers are, the more efficient their visits will be. For other providers, a review of the latest in evidence-based treatment guidelines may be required to ensure appropriate care is provided and that patients are guided on their path to better health. In the RHC setting, the patient flow must be well organized to accommodate those seeking help with chronic care. Episodic visits for acute illnesses or injuries require an average of about 20 minutes, but routine follow-up visits for the patient with diabetes may extend to an average of 30 minutes.

Adherence to a treatment plan is more likely to occur if care is readily available when it is needed and when the care is made most convenient for the patient. Patients with diabetes require more medical appointments than the average person and, therefore, may be more concerned about missing work. They may have increased anxiety about keeping all of these appointments, given their reliance on employment for medical benefits. For these patients, the benefit of being able to have a glycated hemoglobin (A1C) test performed outside of work hours can be enormous. If the patient is not required to make an appointment, the convenience is even greater. Point-of-care A1C instruments provide immediate feedback about average glucose levels, and providers can use this real-time data to make changes to a patient’s treatment plan without having to wait for outside lab results.

It is important to note that certain conditions can interfere with accurate A1C levels, so it is recommended that RHC monitoring not be used in patients with the following conditions: hemolytic anemia, recent transfusion, blood loss, iron deficiency anemia, iron deficiency anemia due to pregnancy, hypertriglyceridemia, hyperbilirubinemia, uremia, chronic liver disease, uremia, hemodialysis, opioid addiction, or alcohol abuse.

If these conditions are present, it is recommended that a fasting plasma glucose level or the 75-g oral glucose tolerance test (OGTT) be used for monitoring.

Race and ethnicity should also be considered in decisions about diabetes monitoring tests. When comparing a series of self-monitored blood glucose (SMBG) results with A1C levels, results of estimated average glucose levels (mean of the SMBG results) revealed that Hispanic patients had the highest A1C rates per SMBG level, followed by Asian patients and black patients of African descent, with white patients having the lowest rates.

Health care providers may opt to use a fasting plasma glucose level or the 75-g OGTT to further evaluate Hispanic, Asian, and black patients.

Clinical updates on “Standards of Medical Care” for patients with diabetes of all ages are published annually by the American Diabetes Association (ADA) in their journal

Every clinician should seek access to this journal to stay up-to-date. The annual supplement is available at

http://care.diabetesjournals.org/content/37/Supplement_1.toc

at no cost. It emphasizes the importance of individualized diabetes care, rather than a one-size-fits-all approach.

In 2010, Patrick Conlon, a board-certified FNP, conducted a study that compared the role of a diabetes nurse practitioner’s (NP’s) practice behaviors with those of physician colleagues in the same primary care setting. It became evident that diabetes management is an intense undertaking and that the NP’s knowledge base, focus on patient care outcomes, and ability to perform patient education all played a key role in the management of this chronic disease.

Borrowing from the methodology described in Conlon’s research, it is important to obtain all baseline data on your patient who has diabetes, which includes a thorough history of their previous diabetes-related outcomes.

This is important for determining the appropriate individual approach. RHC organizations can develop a tracking tool (a diabetes flow sheet) that incorporates the ADA’s national standards and is built right into their electronic medical record system. This should be updated in partnership with the patient at every visit. Patient education should also take place at each encounter and be well documented, as should clinical outcomes. These outcomes should include measurements of A1C, blood pressure, weight, and glucose levels. In Conlon’s research, although there were no real differences in the patients’ blood pressure outcomes when comparing the NP’s and medical doctors’ (MDs’) patients, the average A1C for the NP’s patients dropped by 2.5% compared with the MDs’ decrease of 0.2%.

In addition, the glucose levels were most significantly improved, with a decrease of 83.7 mg/dl in the NP patient group compared with 27.4 mg/dL decrease in the MDs’ patients.

Prescribing medication refills, ordering laboratory tests, and adjusting medications in order to reach metabolic goals was labeled as “routine care” by Conlon.

Routine care plus education, goal setting, and frequent follow-up visits (initially 3 or 4 times a month to ensure acceptance and observance of the established goals) were labelled “diabetes strategies.”

The latter was the strategy taken by the NP who achieved greater success than his/her MD colleagues in providing effective care and management of patients with diabetes.

In terms of initial hyperglycemia management, it is important to assure that the patients gain a good understanding of hyperglycemia and know that it is the main cause of organ damage.

Stringent glycemic control is important, and current guidelines suggest monotherapy for only 3 months before adding another agent, if indicated. The second agent could be another oral agent, a glucagon-like peptide 1 receptor agonist, or insulin.

Goal-setting and tracking sheets that include an “eating plan” and an “activity log” can sound more inviting and useful to a patient simply by moving away from words like “diet” and “exercise.” With regard to alcohol consumption, a recent review revealed that moderate alcohol consumption (particularly wine) reduced the risk of cardiovascular event and mortality.

It’s important that patients who manage their diabetes with insulin or insulin secretagogues be made aware of the delayed hypoglycemia after consuming alcohol. They should also limit their alcohol intake to 1 drink per day for women and 2 drinks per day for men.

In summary, the convenient health care clinic is a suitable environment for the comanagement of patients with diabetes and offers enormous potential to significantly impact clinical outcome measurements and improve population health. It would be prudent for larger traditional health care systems to seek out RHC organizations for partnership in comanaging their patients with diabetes. Health care providers in these settings are best suited to educate patients with diabetes and to individualize the most effective evidence-based care that is so vital for this vast and growing population of patients.

is a board-certified family nurse practitioner and state practice manager of (Central/South) Florida for CVS Health/Minute- Clinic. She is currently earning her Doctor of Nursing Practice degree.

Zitkus BS. Update on the American Diabetes Association standards of medical care.

2014;39(8):22-32. doi: 10.1097/01.NPR.0000451880.48790.50.

American Diabetes Association. Standards of medical care in diabetes.

2014;37(suppl 1):514-580. doi: 10.2337/dc14-S014.

New standards of care reflect trend toward individualized care [press release]. Alexandria, VA: American Diabetes Association; December 19, 2013.

www.diabetes.org/newsroom/press-releases/2013/new-standards-of-care-2014-1.html

Conlon PC. Diabetes outcomes in primary care: evaluation of the diabetes nurse practitioner compared to the physician.

Articles

With the Affordable Care Act's expansion of health care coverage and the shortage of primary medical homes, outcome-based chronic disease management requires an innovative approach.

Kathleen M. Dailey, MS, ARNP

Articles

Managing Diabetes Treatment in the Retail Clinic