Convenient Care for an Inconvenient Condition: Helping Empower the Patient

October 20th 2015
Felicia Spadini, MSN, NP-C
Felicia Spadini, MSN, NP-C



Approximately 5.8% to 12.9% of children and adults in the United States are living with diabetes, and thousands more are diagnosed daily.1The management and treatment of the condition varies depending on whether the individual has type 1 diabetes (T1D) or type 2 diabetes (T2D). However, all newly diagnosed patients with diabetes face a daunting imperative to make healthy choices and appropriate lifestyle changes.2Education, support, and access to care are essential to maximize each individual’s ability to contribute to his or her self-care and minimize the risk of acute and chronic complications. The empowerment of patients diagnosed with diabetes is key to gaining control and ensuring increased quality of life. To make certain that all aspects of care are met, a spectrum of health care providers is necessary.2

Background

T1D accounts for 5% to 10% of diabetes cases in the United States. It results from the destruction of insulin- producing cells.3Onset is usually asymptomatic until the pancreas is unable to produce enough insulin to prevent hyperglycemia.2Newly diagnosed patients should be counseled that the condition is chronic and requires daily monitoring of blood sugar, as well as treatment with insulin.4Patients must also be taught to recognize the signs and symptoms of life-threatening acute complications of T1D, including severe hypoglycemia and diabetic ketoacidosis.

T2D accounts for over 90% of diabetes diagnoses in the United States.3It results from a combination of insulin resistance and impaired insulin secretion.5Although onset may occur at any time, occurrences have increased in children as rates of childhood obesity have risen.6Management generally involves 1 or more oral medications, injectable insulin, or a combination of both.

Newly diagnosed patients require education regarding recognition of signs and symptoms of serious complications, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. Additionally, patients using injectable insulin must be taught to understand the risks and recognize the symptoms of severe hypoglycemia. Newly diagnosed patients with either type of diabetes should participate in a comprehensive diabetes education program that covers nutrition, exercise, and the importance of glycemic control to minimize risks of short- and long-term complications.2Online resources that offer education reinforcement, support, and advice are another important component of optimal self-care. Additionally, all patients with diabetes require counseling regarding their increased risk of infection, neuropathy, coronary artery disease, retinopathy, stroke, nephropathy, and vascular disease.7Finally, patients with diabetes should be advised that frequent physical exams are necessary to monitor efficacy of treatment and development of complications.8

Role of the Retail Health Provider in Diabetes Management

Retail health providers are an integral part of the team providing care for patients with diabetes. They provide screening, monitoring, and reinforcement of education, as well as support for acute and chronic conditions that may arise. Easy access to vaccines and care for minor illness is another manner in which providers in the retail health setting contribute to the overall care of patients with diabetes.

Since T2D usually causes no symptoms, screening is often the only method of discovery.9Glycated hemoglobin (A1C) testing and general health screens that measure fasting blood glucose are part of the initial screening for diabetes. Patients with A1C values of 5.7 up to 6.4 are directed to repeat the A1C test yearly.10Those with hemoglobin A1C values of 6.5 and higher require more urgent care.10Retail health care providers should facilitate follow-up with their patients’ primary care provider or with the emergency department depending on whether the patient is asymptomatic or experiencing symptoms. For a patient with a previous diagnosis of diabetes, A1C tests should be performed every 3 to 6 months, depending on whether the patient’s blood sugar is well controlled or not.8In this instance, the A1C test provides important feedback regarding the efficacy of current therapy.

Another service offered in the retail health care setting is a general health screening that measures cholesterol, fasting blood glucose, height, weight, body mass index (BMI), waist circumference, and nicotine use. These tests screen for diabetes risk and offer other important feedback about a patient’s general state of health. Fasting blood glucose values of 100 to 125 indicate impaired fasting glucose; values of 126 or higher are diagnostic criteria for diabetes, with a second confirmatory test.11Patients with poor cholesterol values or unhealthy BMI are prompted to partner with their primary care provider for further evaluation and care options.

New-onset diabetes, especially in the childhood and teen years, may present as an emergent condition.12Retail health providers are trained to recognize the signs and symptoms of acute diabetic emergencies such as hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. In these instances, fast action and facilitation of proper care are required and may prove lifesaving.

It is well known that patients with a diagnosis of diabetes are at high risk of acquiring acute infections.7Retail-based clinics provide patients access to vaccines designed to prevent or minimize infectious diseases. Additionally, retail-based clinics offer expanded opportunities to obtain care through regularly offered business, evening, and weekend hours. Since patients are seen on a “walk-in” basis rather than by appointment only, treatments for urinary tract infections, skin infections, and other acute problems may be received in a timely manner. This increased access to care reduces the risk of complications from delayed care.

A final contribution to the overall care of patients with newly diagnosed diabetes that retail health providers can offer is empowering patients to contribute to their self-care. Reinforcement of education and support of healthy lifestyle choices is key to maintaining each patient’s daily participation.13Counseling on topics appropriate to the individual, such as smoking cessation, weight control, nutrition, and healthy blood pressure, may also be discussed to maximize the 15-minute window of opportunity during exams for unrelated issues. Additionally, retail health care providers may offer important reminders for patients to seek routine physical exams, yearly foot exams, and yearly eye exams, and may also help to facilitate a relationship with other health care providers such as dieticians, social workers, diabetes educators, and physical therapists when needed.

Felicia Spadini, MSN, NP-C, is a board-certified nurse practitioner. She began her career as a registered nurse in emergency medicine and then worked in the cardiothoracic step down unit for several years. On the unit, she was a certified diabetes resource nurse and a certified wound/skin care nurse. As a nurse practitioner, she has worked in the retail health care setting since graduating in 2013. Her passion is research and providing education for peers and patients alike.

References

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  2. Chiang JL, Kirkman MS, Laffel LM, Peters AL; Type 1 Diabetes Sourcebook authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association.Diabetes Care. 2014;37(7):2034-2054. doi: 10.2337/dc14-1140.
  3. McCulloch DK. Classification of diabetes mellitus and genetic diabetic syndromes. UpToDate website. www.uptodate.com/contents/classification-of-diabetes-mellitus-and-genetic-diabetic-syndromes. Updated October 6, 2014.
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  7. Complications. American Diabetes Association website. www.diabetes.org/living-with-diabetes/complications/.Accessed?
  8. McCulloch DK. Overview of medical care in adults with diabetes mellitus. UpToDate website. www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus. Updated May 6. 2015.
  9. Pirart J. Diabetes mellitus and its degenerative complications: a prospective study of 4,400 patients observed between 1947 and 1973 [in French].Diabete Metab. 1977;3(2);97-107.
  10. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes.Diabetes Care. 2009;32(7):1327-1334. doi: 10.2337/dc09-9033.
  11. Nathan DM, Davidson MB, DeFronzo RA, et al; American Diabetes Association. Impaired fasting glucose and impaired glucose tolerance: implications for care.Diabetes Care. 2007;30(3):753-759.
  12. Klingensmith GJ, Tamborlane WV, Wood J, et al; Pediatric Diabetes Consortium. Diabetic ketoacidosis at diabetes onset: still an all too common threat in youth.J Pediatr. 2013;162(2):330-334.e1. doi: 10.1016/j.jpeds.2012.06.058.
  13. Wahowiak L. Eight tips for caregivers. American Diabetes Association website. www.diabetes.org/living-with-diabetes/recently-diagnosed/8-tips-for-caregivers.html. Published March 2014. Updated March 27, 2015.

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