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Aine Cryts is a freelancer based in Boston. She is a frequent contributor to Managed Healthcare Executive on topics such as diabetes, oncology, hospital admissions and readmissions, senior patients, and health policy.
Getting diabetic patients to adhere to medication and dietary changes can be difficult. Here are some tips from experts.
Family physician Marcus Blackstone, MD, puts his finger squarely on the cost of insulin as a key reason patients fail to comply with their treatment regimens. Thus, Blackstone, who treats patients at Bon Secours St. Francis Health System in Greenville, South Carolina, recommends that payers and providers partner to create more affordable options for patients’ medications.
Insulin vials typically cost patients with insurance as much as $50 a month, and the cost of pens runs close to $100 a month, says Blackstone. For patients without insurance, vials set them back more than $300 a month and pens more than $445. In addition, you’ll find very few diabetes patients who are just on insulin; they often have multiple other conditions along with diabetes, he adds.
During conversations with patients, Blackstone says primary care providers need to continually reinforce the long-term complications associated with the disease, and the need for active monitoring and dietary changes.
Patricia Bononi, MD, medical director of the Center for Diabetes at Allegheny Health Network in Pittsburgh, describes diabetes as an “overwhelming” disease. “The majority of treatment falls in the hands of patients who are faced with food choices and activity choices every day. Basically, everything they do affects their diabetes,” she says.
Thus, Bononi advises physicians to stop making assumptions about patients’ diet choices, for example. It’s not as simple as poor access to food, she says. Often, it’s because patients don’t know how to cook those foods. Or, if their medications are too expensive, it could be that they’re too embarrassed to tell their physicians that they can’t afford them.
Another reality is many patients have high-deductible plans. Many physicians will assume that if their patient is employed that they should be able to afford their medications. Insulin, however, represents a significant out-of-pocket expense for these patients, she says.
Here are nine ways physicians can help their diabetes patients adhere to their treatment plans:
1. Seek community support. Not everyone has access to a nutritionist, says Bononi, who recommends that physicians connect patients with food insecurity issues to a local food pantry. Further, she has advice for food pantries serving diabetic patients: Teach them how to cook the healthy foods available at the food pantry. “It all comes down to communication,” she says. “You have to meet patients where they are.”
2. Educate nearby skilled nursing facilities on nutritious food choices. For example, Blackstone recommends having a diabetes educator walk through the kitchens of these facilities to assess the relative healthiness of the food provided to patients. He notes that while Bon Secours St. Francis doesn’t own the 10 skilled nursing facilities where the health system sends patients, the facilities are grateful for access to diabetes educators. The health system’s clinicians also take part in weekly calls with these skilled nursing facilities to determine where dietary support for patients is appropriate, he says.
Next: Build relationships
3. Build relationships with patients’ family members. One of the first questions Blackstone asks his patients is: “Who does the cooking in your house?” That’s because he wants this person to come to the patient’s appointments to ensure compliance with the patient’s treatment regimen.
He then educates the primary cook about proper nutrition (for example, by explaining that carbohydrate-dense foods convert into sugar within the patient’s body). Most family members aren’t aware of this, he adds.
4. Schedule regular diabetes-specific appointments with patients. Diabetes management is time-consuming and it can’t be squeezed into a brief 15-minute appointment slot, says Cory White, MD, an endocrinologist at Bon Secours St. Francis.
During these condition-specific appointments, emphasize the long-term consequences of uncontrolled diabetes and help patients set achievable goals and targets for their fingerstick blood glucoses and hemoglobin levels, adds White. He notes that working with nonphysician providers such as nurse practitioners and physician assistants can make this possible.
5. Determine the root cause of patients’ resistance to taking medications. Often, patients will be uncomfortable about issues such as weight gain that can be associated with taking insulin, says William Yancy, MD, director of the Duke University Diet and Fitness Center.
It’s also important to clear up any misperceptions that patients may have about insulin. For example, Yancy cites one patient who thought that taking insulin resulted in a friend’s need to have her foot amputated.
6. Practice nonjudgment. Yancy recommends that providers ask this question: “I know that some patients have difficulty taking their medications and miss doses. Has that happened to you? How often?”
Often a physician will think they’re providing clear guidance to a patient on taking their medications, but something gets lost in translation, he says.
7. Use motivational interviewing techniques to tap into patients’ goals. Focus on asking patients about their goals, which could include spending more time with their grandchildren, says Yancy. Focusing on patients’ goals is important, he says, because behavioral change is difficult.
8. Teach patients how to exercise. At the Duke University Diet and Fitness Center, participants learn how to exercise in a safe environment. Often, patients who don’t work out can feel uncomfortable doing so around people who exercise regularly, Yancy says.
9. Pursue strategic partnerships with payers and pharmaceutical companies. In order to educate and encourage diabetic patients about healthy food options, Bononi’s team at the Alleghany Health Network received funding from the Highmark Foundation and educational materials from Novo Nordisk for a program that provided $50 a week to diabetic patients over a period of five months. The 40 patients could only spend the money on fruits or vegetables at a nearby farmers market. Participants also attended three educational sessions about healthy eating, and could tour the farmers market with a certified diabetes educator.
As a result of the program, participants experienced an almost 1% decrease in their A1c levels. Bononi says her team is now working with Highmark to develop an appropriate reimbursement model to support this treatment approach.
Aine Cryts is a writer based in Boston.