How to Assess the Healthcare Needs of Diabetes Patients

 Pharmacists as part of the healthcare team

 

R. Keith Campbell, R.Ph., FASHP, CDE
Associate Dean and Professor of Pharmacy Practice,
Washington State University College of Pharmacy,
Pullman, WA

James Bennett, R.Ph., CDE
J. Bennett Apothecary, Corinth, MS

 

There is an explosion of patients being diagnosed with diabetes; unfortunately, the overall care of patients with the disease remains suboptimal. Over 90% of diabetes patients are followed by primary care physicians who may not specialize in diabetes care and whose time spent with each patient may be limited. Less than one-third of patients with diabetes have been thoroughly educated in diabetes self-management, and only one-third have had a dilated pupil eye exam in the past 12 months. Ninety-four percent of patients do not have their shoes and socks removed for a foot examination during routine clinician visits. Furthermore, even though taking an aspirin tablet daily is a standard of diabetes care, less than 25% of diabetes patients are following this guideline. Hemoglobin A1c (HbA1c) levels should be monitored at least three times a year, but one study of an HMO showed that 55% of their diabetes patients had no HbA1c tests done the previous year. Target HbA1c level is less than 7%, but the average value for type 2 patients in the U.S. is 9.5%. The management of diabetes in our present healthcare system urgently needs attention. This problem poses an opportunity for pharmacists.

Pharmacists can be trained to educate and motivate their diabetes patients to take charge of their condition. In the May/June 2000 issue of the Journal of the American Pharmaceutical Association, an article by Schapansky and Johnson concluded that "pharmacists agree that they should be part of the healthcare team for managing diabetes, that they should be required to have specialized training to provide primary diabetes care, and that they have the skills to become diabetes educators."

An Ashville, North Carolina, project reports continued positive results by having pharmacists provide disease management for city employees with diabetes. Patients managed by pharmacists were able to reduce blood lipid levels, achieve HbA1c levels of 6.2%, and reduce overall cost of diabetes care. Pharmacists in Mississippi are also attempting to improve outcomes of care in diabetes by educating patients and helping to positively impact HbA1c levels.

Many pharmacists are participating in a 70+ hour, ACPE-approved certificate program entitled Pharmacy.  Partners in Diabetes Care, sponsored by the Washington State University College of Pharmacy, CoMed and LifeScan, Inc. Over 900 pharmacists have completed the program's self-study and finishing courses. The National Community Pharmacists Association and the American Pharmaceutical Association also offer diabetes programs. Pharmacists make up the fastest growing group to become Certified Diabetes Educators (CDEs) through the National Certification Board for Diabetes Education.

Making a Difference

More than 40 states have passed legislation that allows pharmacists to be reimbursed for educating patients. Many pharmacists prefer having their productivity measured by the impact they make on patient care rather than by the number of prescriptions they fill each day. Consider that if reimbursement is AWP minus 17% plus $1, each prescription filled will cause a pharmacy to lose $6 or more. To increase profitability while improving patient outcomes, pharmacists must prove they make a difference. They must document their interventions and then bill for these cognitive services.

Table 1. Patients at High Risk of Developing Diabetes

Overweight with abdominal obesity Age over 40 years Family history of diabetes Patients with hypertension Patients with hyperlipidemia Women who have given birth to babies over 9 lbs. Individuals with a birth weight of over 9 lbs. African-American patientsa Spanish-speaking patientsb Native Americans and Pacific Islandersc   aAfrican-American patients have double the incidence of diabetes compared to Caucasians bSpanish-speaking patients have triple the incidence of diabetes compared to Caucasians cNative Americans and Pacific Islanders have quadruple the incidence of diabetes compared to Caucasians

Federal legislation mandated that Medicare recipients receive coverage of diabetes products and that certain healthcare providers (HCPs) who are trained in diabetes management be reimbursed for educating patients. Pharmacists are not considered HCPs by Medicare, but there is a move under way to change the regulations and allow qualified pharmacists to apply for a healthcare provider number. Such a designation would allow pharmacists to bill for certain clinical and educational services. In addition, over 40 states have passed legislation mandating that insurance carriers cover diabetes supplies and reimburse for diabetes education. Pharmacists can also sell products that make living with diabetes easier. One study has shown that each diabetes patient generates, on average, $750/year in profit to the pharmacy if he or she purchases diabetes care products in that pharmacy.

Interventions

A team approach involving the patient, physician, and diabetes educator (nurse, dietitian and/or pharmacist) has proven to result in a lowering of the patient's HbA1c values, reduced acute and chronic complications, decreased hospitalizations, and improved quality of life. When pharmacists are involved in diabetes care, the patient feels better and has fewer health problems, the healthcare system saves money, and the pharmacist makes a difference and is reimbursed for professional interventions.

Identification: First, pharmacists must identify patients with diabetes. This includes both the diabetes patients who are already being followed and those who have diabetes and do not know it. Patients at high risk of having diabetes are summarized in TABLE 1.

Assessment: Patients who adhere to the Standards of Diabetes Care (published by the American Diabetes Association) have improved outcomes. Thus, one of the methods a healthcare provider can use to develop a treatment program for a patient is to evaluate the patient's adherence to the Standards of Diabetes Care (see TABLE 2 for a summary).

Assessing the status of care for a patient with diabetes is crucial for devising a successful treatment plan. Once an assessment is completed, the pharmacist or other HCP can develop short- and long-term plans to improve the care of the individual patient. When necessary, referral of patients to other providers should also occur.

Education: Educating patients with diabetes about their disease helps empower them. Also, pharmacists play a relatively unique role as educators by providing numerous diabetes care products and instructing patients on their proper use.

Table 2. Standards of Diabetes Care

Check the following at least three times a year: Random or fasting blood glucose Hemoglobin A1c Weight and height Blood pressure (should be <130/85 mmHg) Feet examination Cardiac status and/or risk Skin care Analysis of daily self-monitoring of blood glucose results Medication/insulin regimen Other medical conditions and their treatments Nutrition plan Exercise plan Frequency of acute diabetes complications Long-term complications, such as neuropathy, gastrointestinal problems, sexual dysfunction, infections Smoking status Educational needs Psychological well-being Aspirin use   Check the following annually: Dilated pupil eye exam Neurological status ECG Urinalysis for microalbuminuria, glucose, ketones, protein Lipid values for total cholesterol, LDL, HDL and triglyceride levels

The SOAP Method

The SOAP method is an efficient and effective way of implementing pharmaceutical care of patients with diabetes.

Subjective Information: "S" stands for the subjective information the pharmacist should obtain from patients about their healthcare status (e.g., age, weight, race). Subjective information is gathered through observation and questioning of the patient.

Objective Data: "O" stands for the objective data related to the patient. This includes lab values, such as HbA1c levels, blood pressure, blood lipids, weight, height, kidney and liver function. For most community pharmacists, obtaining objective data requires an effort to contact the physician. The amount of time it takes and the lack of easy access to lab values are barriers to providing pharmaceutical care, but getting objective data is vital in developing a realistic individualized treatment plan.

Assessment: Once the subjective and objective data are collected, it can be assessed (the "A" in SOAP) for areas of concern. Then a problem-oriented medical record, in which the patient's problems are listed in order of severity, can be developed. The assessment step can be enhanced by the development of a diabetes patient assessment questionnaire, which allows the pharmacist to determine specific information about the patient's adherence to the Standards of Diabetes Care.

Plan: The "P" portion of SOAP stands for the plan. Once the assessment is done and there is a listing of the patient's problems, short- and long-term individualized treatment plans can be devised.

This may all sound time-consuming and overwhelming for pharmacists pressured with many prescriptions to dispense. Yet if the process is organized and implemented effectively, the pharmacist can make a significant difference in patient care in a short period of intervention. Pharmacists may find it helpful to send a letter to local physicians explaining their diabetes services and inviting physicians to visit the pharmacy and see the program. Pharmacists can also remind physicians that they will inform them of their patients' progress. This may enhance acceptance of the program.

Benefits of a Patient Assessment Questionnaire

In the case study example, the DIABETES PATIENT ASSESSMENT QUESTIONNAIRE (DPAQ) presented on the following page provides an efficient and effective way to enhance the patient care process. It allows the pharmacist to determine the patient's present level of care and points to what steps are needed to move her to a program that follows the Standards of Diabetes Care. It signals what objective information is needed from the physician (i.e., lab values, presence of complications, and treatments the physician has considered). In addition, by filling out the questionnaire, the patient learns about the management of diabetes and the many diabetes care products available.

The DPAQ can be reproduced and sent to the physician for documentation in the patient's chart. This is important because physicians can be sued for malpractice if they are not confronting the issue of Diabetes Standards of Care and attempting to improve the outcomes of their diabetes patients. The DPAQ also acts as one piece of documentation of the pharmacist's activities that can be used to bill for cognitive patient care activities. The DPAQ takes the patient just a few minutes to fill out and the pharmacist quickly determines the patient's needs. Having the patient fill out this form rather than the pharmacist asking the questions saves considerable time.

Case Study

Mrs. Brown comes into the pharmacy wanting to know what type of aspirin tablet she should take. Her physician told her that it would be good for her diabetes. Pharmacist Jones has the option of saying, "In aisle 29 there is a display of aspirin tablets and they all work the same way. Take whichever one is cheapest," or he can begin a dialogue with Mrs. Brown that has the potential to improve her healthcare outcomes and encourages her return. If the pharmacist documents his activities, he can bill for his time in developing a treatment plan and educating her.

Pharmacist Jones can tell Mrs. Brown: "I am pleased that you came to me to get your questions answered. It is recommended that patients with diabetes take an aspirin tablet each day because it has been shown to reduce the risk of having a heart attack. We recommend to our diabetes patients that they take an enteric-coated 81 mg aspirin tablet. It is inexpensive and works well. Because you have diabetes, I also would like to tell you about the program we have in this pharmacy to help our diabetes patients feel better.

"We have been trained in diabetes care and take pride in working with our diabetes patients to ensure that they are following a treatment program that helps prevent short- and long-term problems. We have had some excellent results. If this is a convenient time for you, I would like you to take a few minutes and fill out this questionnaire. There are no right or wrong answers. After you have filled it out, I can quickly go over it and recommend some simple steps you can follow that may improve your diabetes care. We can then partner with one another and have you come back for sessions that will teach you to take better care of your diabetes. I will also work with your physician and keep him/her informed of our progress. I think you will find that you will feel better and do much better with your diabetes care."

Mrs. Brown agrees to work with the pharmacist, and she completes the questionnaire. He reviews the form and easily determines that Mrs. Brown is not following the Standards of Diabetes Care. She does not know her HbA1c level, her lipid levels, or her blood pressure, and she has not been educated to self-monitor blood glucose or follow any of the preventative steps to reduce diabetes complications. Pharmacist Jones asks her permission to discuss his concerns with her physician and makes an appointment with her for the following week at a time that is convenient for both of them. The pharmacist then calls Mrs. Brown's physician to discuss her case and get as much objective information as possible. He now has subjective and objective data and can assess her needs and develop a problem-oriented medical list and a plan to work on each area of concern. Pharmacist Jones has answered Mrs. Brown's short-term concern about aspirin and started a dialogue with her that will allow the two of them to confront other important diabetes-related issues.

Readers are welcome to reproduce the form and use it for their diabetes patients. Some pharmacies have developed their own forms that are shorter or stress other diabetes concerns. Others have developed a wallet card for patients to carry that reminds them of the Standards of Diabetes Care. The card also has a place for the patient to keep track of lab values, eye examination appointments and other data.

The sample DPAQ is detailed but easy to complete. The questions cover the ADA's Standards of Diabetes Care. From the patient's responses, the pharmacist or other HCP can quickly see areas of concern, allowing development of a treatment plan. For example, if the patient is not trained in preventative foot care, the pharmacist can discuss it in an educational session. If the patient has not had an eye exam for retinopathy, the pharmacist might arrange an appointment with an ophthalmologist trained to diagnose diabetic retinopathy. If the patient is not taking an aspirin daily, the pharmacist can suggest one, if appropriate. Some pharmacists have developed a list to give the patient to remind him/her of products that make living with diabetes easier.

Many pharmacies are creating disease state management programs. Pharmacists with the proper skills and knowledge can proactively intervene in their patients' care by opening a dialogue at the point of dispensing and initiating the completion of a DPAQ.

 

 Diabetes Patient Assessment Questionnaire

Go To Printable Version

PATIENT DATA

Name ______________________________________

Address ____________________________________

Phone number:	Home ( ) ______________
	Work ( ) ______________

Insurance carrier _____________________________
ID # _______________________________________

Who is your primary physician?
___________________________________________

Address and phone number of physician, if known:
___________________________________________

___________________________________________

When did you last see your physician about diabetes?
___________________________________________

Have you been seen by a specialist in diabetes care?

No __ Yes __ If so, please state the name of the specialist. __________________________________

Have you had a dilated pupil eye exam?

No __ Yes __ Date of last exam ________ Results of exam: any signs of retinopathy? No __ Yes __

Have you received any diabetes education?

	No __ Yes __
		If yes, which topics?
	Nutrition or diet info _____ Importance of exercise _____ Foot care _____ Blood glucose monitoring _____ Diabetes complications _____ Diabetes medications _____ Use of insulin _____ Duration of education program? 2 hours or less ____ 2-4 hrs ____ 4-8 hrs ____ Several days ____ Other ________

 

How long have you had diabetes? ________ yrs

Your age or birth date ___________

Please mark the type of diabetes you have.

Type 1 ____ Type 2 ____ Don't know ____

Have you met with a Certified Diabetes Educator (nurse, dietitian or pharmacist) about your diabetes treatment?

No __ Yes __

How do you feel about your diabetes care?

Good ____ Average ____ Poor ____

How do you feel about working to improve your diabetes care?

I feel ready ____ I am not sure ____ I am a bit skeptical or need more info ____

Do you have a Medic Alert tag or bracelet? No __ Yes __

 

Do you have a bathroom scale to weigh yourself weekly?

No __ Yes __ Has your weight changed in the past few months? No __ Yes __

Do you have a device to self-monitor blood pressure at home? No __ Yes __

Do you self-monitor blood glucose levels?

No __ Yes __ If yes, do you keep track of the results of your blood glucose tests? No __ Yes __ What meter do you use? _____________________ How often do you test? ______________________ Have you been trained about how to easily get a drop of blood? No __ Yes __

Do you smoke? No __ Yes __

If yes, would you be interested in attending a smoking cessation program? No __ Yes __

Do you belong to the local affiliate of the American
Diabetes Association? No __ Yes __

If no, would you like information about joining? No __ Yes __

Do you belong to a local diabetes support group?

No __ Yes __ If no, would you like information about a group? No __ Yes __

Would you like any educational reading materials about diabetes? No __ Yes __

Do you frequently have "heartburn" or acid reflux problems? No __ Yes __

Do you feel bloated or nauseated after you eat a meal? No __ Yes __

Are you frequently constipated? No __ Yes __
Do you have any problems with sexual function?

No __ Yes __ If you are a man, do you have erectile dysfunction (impotency)? No __ Yes __ If you are a woman, do you have vaginal dryness? No __ Yes __ If you are a woman, do you have frequent vaginal yeast infections? No __ Yes __

Have you been trained in preventative dental care?

No __ Yes __ Do you brush and floss at least twice a day? No __ Yes __ Do you see a dentist at least twice a year? No __ Yes __ Do you get a new tooth brush at least every 2 weeks? No __ Yes __

Have you been trained in preventative foot care?

No __ Yes __ Do you examine your feet daily? No __ Yes __ Do you have a quality pair of nail clippers? No __ Yes __ Do you rub lotion on your feet each night? No __ Yes __ Do you have a mirror to help you see all areas of your feet? No __ Yes __ Do you frequently have athlete's foot? No __ Yes __ Do you have fungal infections of your toe nails? No __ Yes __ Have you been trained as to how to break in a new pair of shoes? No __ Yes __ Would you like me to test your feet for neuropathy? No __ Yes __

Do you take a daily multivitamin that is high in antioxidants? No __ Yes __

Would you like information about the need for vitamins C and E, folic acid, magnesium, zinc, selenium, chromium, calcium, B vitamins? No __ Yes __

Do you take any "natural" or "herbal" remedies for diabetes? No __ Yes __

If yes, please list: ___________________________

Do you suffer from any diabetes complications?

No __ Yes __ If yes, which ones? _________________________ _________________________________________

 

	Please circle any of the following that you have:
	Neuropathy in hands or feet Retinopathy or other eye problems Kidney problems Heart problems Frequent urination Skin problems Bladder infections Frequently tired Pain in legs after walking Other (please list) ___________________________ _________________________________________ _________________________________________

Has your physician checked the back of your neck for dark patches? No __ Yes __
(The presence of dark patches is a symptom of insulin resistance called acanthosis nigricans.)

Do you ever have low blood sugar levels (hypoglycemia, insulin reactions)? No __ Yes __

Do you carry glucose tablets to treat low blood sugar?

No __ Yes __

Do you own and have you been trained to use a Glucagon Emergency Kit? No __ Yes __

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LABORATORY VALUES

Have you had your hemoglobin A1c (HbA1c, glycosylated hemoglobin) level measured?

No __ Yes __ Don't know __ If yes, what was the last value? _______ % When was it last measured? ________________

What was your last fasting plasma glucose value?

Don't know ____ or ______ mg/dL

Have you ever been tested for protein in your urine (microalbuminuria)?

No __ Yes __ Don't know __

Have you ever had ketones in your blood or urine?

No __ Yes __ Don't know __

What are the values for your blood pressure?

Systolic _____ Diastolic _____ Don't know ____ [Blood pressure goal is <130 (systolic)/85 (diastolic) mmHg]

What are your blood lipid (fat) values?

HDL _____ LDL _____ Total cholesterol _____ Triglycerides _____ Don't know ____ When were your blood lipid values last tested? ___________________________________

Please state your weight: ________lbs.
Your height: ____ft. ____inches
(BMI can be calculated from these values __________) [pharmacist will fill in]

If you are a woman, have you had a bone density screening (for osteoporosis)? No __ Yes __

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TREATMENT FOR DIABETES

Have you met with a dietitian and had a nutrition program prescribed? No __ Yes __

If yes, do you limit calories? No __ Yes __ If yes, do you count carbohydrates? No __ Yes __

Do you consume alcohol? No __ Yes __

If yes, how many drinks per day? Beer ____ Wine ____ Liquor ____

Do you follow a prescribed routine exercise program?

No __ Yes __ If yes, for how long and how many times a week? _______________________________________ Type of exercise: Walking ____ Running ____ Weight training ____ Other _______________

 

 

Do you inject insulin to treat your diabetes?

No __ Yes __ If yes, which type of insulin and how much and how often do you inject? Insulin type ________ Daily number of units _____ Injections/day _________ (Insulin types include NPH, Regular, Humalog, Lantus, Ultralente, Lente or Mixtures)

Do you take any oral agents to treat your diabetes?

No __ Yes __ If so, circle the medications you take and fill in the dose and how often you take them. Glyburide (Glynase, Micronase, DiaBeta), glipizide (Glucotrol or Glucotrol XL), or glimepiride (Amaryl) __________________________________ Metformin (Glucophage) ______________________ Acarbose (Precose) or Miglitol (Glyset) __________________________________________ Pioglitazone (Actos) or Rosiglitazone (Avandia) __________________________________________ Repaglinide (Prandin) ________________________ Nateglinide (Starlix) __________________

Has your pharmacist or doctor told you:

How and when to take your medications? No __ Yes __ How to store your medications? No __ Yes __ Do you have any questions about your medications? No __ Yes __

Do you take any medications to treat high blood pressure? No __ Yes __

If yes, please list the medication's name(s): _________________________________________

Do you take any medications to treat high blood fats (cholesterol, triglycerides)? No __ Yes __

If yes, please list the medication's name: _________________________________________

Do you take any medications to treat diabetes complications? No __ Yes __

If yes, please list the medication's name: _________________________________________

Do you take any medications to treat any other conditions? No __ Yes __

If yes, please list all of the medications: __________________________________________ __________________________________________ __________________________________________

OTHER TOPICS

Please list any other healthcare issues that you would like to discuss:

1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________

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FOR EDUCATOR’S USE:

TOPICS THAT NEED ATTENTION:

TREATMENT PLAN:

Short-term plan: Next appointment ___________________________ Information needed from physician: _________________________________________ _________________________________________ Other:   Long-term plan:

 

Dates of Interventions		Time Spent with Patient