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Nancy D’Hondt 2018 Transcript

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Freed: This is Steve Freed. We’re here at the 78th Scientific Sessions from the American Diabetes Association, and today we have a special guest. Are you presenting this year?


D’Hondt: I am not, no. I don’t have enough time. (Laughs)

Freed: She’s very unique. She’s an RPh, CDE, FAADE, past president of the American Association of Diabetes Educators, and very actively involved. So, why don’t you start out with giving us a little bit of information about yourself and what you do?

D’Hondt: So, I work inpatient, outpatient. I work for Ascension Health. I do the bulk of my job as inpatient pharmacy, setting protocols, nurse education, staff education, looking at formularies. I work with our outpatient diabetes education program, which is a certified program. I teach with them, help with some patient uptake, evaluations. I work for an independent pharmacy and I work for a long-term care facility.          

Freed: I always had this nightmare dream that when I was a little kid my dad would take me to the Museum of Science and Industry. And we’d go downstairs where they had the old city and there’s an old fashioned drugstore. And we walked in there and there’s a model of a pharmacist with a white coat. And I would say to my dad, “Who’s that?” and he’d say that’s a pharmacist. And I’d say to my dad, “What is a pharmacist?” and he says, “Well, that’s someone who fills your prescriptions and talks about the medication,” and I said to him, “That’s stupid. We have computers that do that.” And I recently was in a pharmacy where they had a machine that you put your ID card in and your prescription pops out. So, that’s one of the reasons I go to pharmacy schools and talk to pharmacists, why they need to get more involved with patient care. And I think that’s where pharmacy is going. It’s changing.

D’Hondt: They are. So, getting more into the clinical space. It’s taking longer to get through pharmacy school, that’s why they have a Doctor of Pharmacy [degree] now. They’re doing more of the clinical interventions, and recommendations, and patient management, and for most of the chronic diseases there are specialists.

Freed: So, it’s coming.

D’Hondt: It is.

Freed:  I don’t know if I’ll be around, but it’s taking so long.

D’Hondt: We’re working on prescriptive authority across the board.

Freed: Right.

D’Hondt: Yeah.

Freed: And they really needed my idea of pharmacist. And I helped a lot of students get involved. It’s that you find a friend who’s a doctor or a relative and say, “Can I come in one day a week and help manage your diabetic patients?” and you can share them, giving them 50% of what you charge for an office visit. So, there’s ways to do it. And students just need to — I get to work with interns. My partner, we have about three interns every month that work with us on our newsletter. And I talk to each one of them about getting more actively involved. From what I can tell — they’re going for their PharmDs– is that I can tell that pharmacy is changing by what their requirements are and so forth, which is good. I wish I could go back to pharmacy school and start all over.

D’Hondt: That’s right, we’re the experts.

Freed: So, education is a key component of type 2 diabetes. I always believe that without the education a person is doomed for failure no matter what drugs you give them including insulin, if he really doesn’t understand the benefits in physical activity and nutrition, and everything. And I always  say that the physician doesn’t always have the time. We all know that. They can’t get paid for it. But I personally feel that it’s their responsibility to get the patient educated however that may be. One of their jobs is to make sure that they follow up with that patient and make sure that they are getting educated. So, the physician needs to have the places available and the cost and whatever to the patient so that he actually signs the patient up before they walk out of the office. And I really think that’s what physicians need to be. So, if education works why is it that what I just said isn’t happening? Why aren’t physicians getting their patients educated? Because I talk to type 2s all the time, nobody mentions education, pretty much, on a majority of time.

D’Hondt: I think education is a scary word. And I think that we’re, as an association, we’re looking at starting to change that dynamic. It’s about self-management. It’s about helping build the skill sets. Where we interpret it as education for the patient, it’s learnings; learning how to manage, learning what to do, learning how to deal with the daily routine of diabetes. It’s overwhelming. There’s a lot to know. There’s a lot of medications. You have to know how to take them. You have to know what to eat, what not to eat, how it will affect your blood glucose. It’s all about numbers. What are your blood pressure numbers? What are your lipid values? And I think that giving them the skills to understand, our understanding what their needs are, and then giving them the skill set, they’ll be able to manage on their own. They see a health care provider 0.07, I think, percent of the time in a year and they spend the rest of the time by themselves. So, giving them the skill sets to self-manage while they’re not in the presence of the health care provider as well as delivering the contact points that they’ll have in that time alone: peer support groups, technologies, access to an educator; those are all things that are important to helping to build those skills and give them the confidence to better manage their chronic disease. It’s not going to go away.

Freed: And so, there’s been a number of times where I got community to participate and open up the library and invited people to come, and learn about how to prevent diabetes, how to treat diabetes. And they put it in the newspapers and they put it on the cable channels, and three people show up in a community of 100,000, 200,000 people. And that’s one of the issues is that if you tell a patient to get educated, that’s where it ends. They really don’t act upon it. So, what is AADE [American Association of Diabetes Educators] — and that’s where it needs to come from — what are they doing about it?

D’Hondt: So, we’re actually looking at integrating the educator — and that term may be changing as we move forward to be more in line with what we think we should be doing — but integrating care and self-management care, and those skill set and teachings into the fabric of health care delivery. So, as we look at population health and value based care, we’re not looking at a service and you silo the services. You go here for your dental appointment. You go here if you have heart disease. You go here for your education. We think that those things should be coordinated and the care should be across the continuum and access points should be continually being reached by the patient and given to the patient. And that the educator will be ingrained in that fabric of the health care team. So, everyone — it won’t be about access. It’ll be about the delivery points.

Freed: And one of the big things, and I don’t hear too much discussion about it, is that we know there’s 30 million people with diabetes, 10% of them are type 1s. But we know there’s approximately, and we’re just assuming with the numbers that we have, that there’s probably close to a 100 million people with pre-diabetes that are on their way to becoming diabetic. And if we’re  spending $360 billion today for the 30 million, what are we going to spend for 100 million when they start to lose their limbs and their kidneys? I just can’t comprehend why we’re not doing anything. And I don’t even know that even AADE from my experience is really pushing that aspect. I mean, if it was me I would have every person filing an income tax return have to fill out one of the American Diabetes forms that detects whether you’re at risk for diabetes by filling in five little squares with numbers or check marks that we could — I mean, why isn’t that being done?

D’Hondt: So, it is. So, we have prevention programs. We’re working with the CDC. They resurrected the data from the DPP and did some studies with the National DPP Program trying to roll it out. We have had a five-year contract. Our outcomes data that we reported to them under the original grant were as good if not better than what the health coaches — that was the Y programs and the programs that were accessible in the communities. And we wanted to compare community with life coach trainers compared to lifestyle coach trainers that were actually CDEs or experienced diabetes educators. Our outcomes data is good. We re-upped. We have another grant going with the CDC. I think the biggest barrier is because — and I listened to a talk yesterday. It’s like running out of gas or changing your oil. If you run out of gas, you have an immediate effect. Your car stops. You don’t go any further. That’s a problem. So, you have to take care of it. You don’t run out of gas. You’re conscious about it. Your oil, you don’t have an immediate effect if you go beyond the marker of having to change it. So, people with chronic diseases, there’s not an immediate effect for them not taking care of it, unless maybe you’re a type 1. But for most patients with chronic diseases, there’s not an immediate effect that they feel differently or poorly all of a sudden, so they push the envelope. And if I don’t feel bad or bad enough to go to see a health care provider, I’m not going to take care of it. I think the same thing is with DPP. It creeps up on them until they are broken. And we don’t have an initiative nationwide to really push the prevention envelope. We talk about it but we don’t practice it. And even with self-referral for the Medicare patients, they’re not bringing them in. I don’t think we’ve explored the avenues for giving them the value-based proposition behind it. I don’t think that we’ve partnered with, for instance, the AARP. They have a big influence on seniors and those who have Medicare. But AARP is not pushing this out to their seniors and letting them know. We’re not going into the senior centers and providing programs. We’re not going to where they live and where they hang. So, I think we really to look at where are the access points for them and making it accessible for them rather than waiting for them to come to us. And I think that’s some of what we’re looking at.

Freed: That’s interesting because what you’re talking about is educating people with pre-diabetes. What I find is that that’s only 10% of a 100 million. The other 90 million have no clue. They don’t even know they have pre-diabetes and that’s really where the impact needs to be as far as educating enough public that they have pre-diabetes. If we sent that form out, it’s available on ADA with every tax return, or every drivers license you have to go — you have to have an eye test, we have a diabetes test. I mean, to me that’s so simple. It’s stupid.

D’Hondt: That’s a good idea. (Laughs)

Freed: That if 90 million people knew they had a disease called pre-diabetes, I guarantee you half of them would take a more active role in going for a walk. The American Diabetes Association should sponsor, get a dog. I mean, there’s so many ways we could do it. We’re so focused in on the cure for type 1 or cure for type 2 that we lose aspect, that the real problem is not even here yet.

D’Hondt: We’re not stopping the wave that’s coming behind the tidal wave.

Freed: And I can understand why because when it comes to diabetes there’s so many things involved; you’ve got kidney issues, you’ve got eyesight, you’ve got neuropathy. There’s just so many things that everybody is working on, that we don’t have time to worry about pre-diabetes. We’re going to wait until it’s a trillion dollar business.

D’Hondt: We’re trying but it’s just — I don’t think there’s a big enough push. I think that it has to be a multi-organizational, multi-institutional, as in government has to stand behind this and really help push this because you know that diabetes is the underlying cause of a lot of these other chronic disease. Heart disease, 80% of those patients that have heart disease have diabetes. But heart disease gets a lot of attention and diabetes gets put on the back burner. Why is that?

Freed: Well, what I’ve done in the past is really push A1C numbers. And I know it’s not messiah to everything but I call it the quality of life test, because that number determines when you’re going to live or die. That number determines your risk factor for every disease known to man whether it’d be athlete’s foot to dry skin. Somehow because sugar is attached to every red blood cell and the red blood cell is everywhere in our bodies, that it affects our whole immune system and increases our risk for all kinds of things including cancer and Alzheimer’s and all those wonderful diseases. So, I try to push A1C that everybody on this planet should have, know what their number is. And if you know what your Social Security Number is you should certainly know what your A1C is. And once you know what it is and what it represents and how that increases your risk for every disease known to man, then it’ll motivate people and I’ve proven that. I went to the electric company in Illinois. They asked me to come in and do a presentation to their employees. And so, I went to this plant where they had 200 employees. And I did a presentation every eight hours, there were three eight hours shifts because they worked 24 hours, talked about the importance of the A1C. And I offered, they paid for it, I offered to do an A1C test after my presentation. And I had all 200 waiting in line wanting an A1C test. And first time in my life, I worked 24 hours straight with no bathroom or eating breaks doing A1C. The next time, because I went to three plants, I brought two people with me. But the first time I never thought — so the point is that if you present the information properly or motivate them, they’ll want that number.

And then I came back 90 days later to review the A1C, I dropped the A1Cs 40% because most of the people were overweight, they’re in their 40s, 50s, 60s. They’ve been around for a long time and their A1Cs were elevated. It’s around 30% with pre-diabetes, but I didn’t even really promote the diabetes aspect. I promoted that quality of life concept that this number represents how well your health is. And like I said I dropped the average A1C about 40%. And they asked me to come back to do it for their other plants and — but then I learned after that year I said, “You know what, I’m not going to charge you a fee. I want half of what I saved on your medical expenses,” because I had to save millions of dollars. So, I think as you do presentations and the diabetes educators are more actively involved that they all have great ideas, because they’re dealing with the problem and they could see where the areas are.

Freed: Changing the story a little bit, one of the issues we have is the cost of insulin. What do you think or why do you think insulin is so expensive? Because we know it doesn’t cost anywhere near what they’re billing for insulin. I keep telling patients to go to Walmart and get the regular insulin, and it’s 25 bucks and you don’t have to spend that kind of money.

D’Hondt: It’s true. It’s true. And I think that as we moved away from NPH and regular insulin and got into these new longer acting more physiologic insulins, the prices went up. The problem is that they made them not affordable for anyone. I think that, I don’t think you can point a finger at one person. I think it goes all the way up the chain. I wish we could do a tracer on a drug where someone would purchase it and you could track it back through the warehouses, through the PBMs to find out where the biggest price jumps are and who’s adding the most amount in that cost factor to the ultimate buyer at the counter. And you have to wonder, are we pushing people back into NNR? They’re very effective as you know, you can get good outcomes with NNR. Is there a bigger risk for hypoglycemia? Likely, yes. Are there patient populations that shouldn’t use it? But we should be looking at how do we make the most effective medications available to anyone who needs them and they should be affordable. No one should have to give up food or the ability to live comfortably in a house with heat because they have to worry about insulin.

Freed: So, what do you think we should do about it? I mean, what can we do about it?

D’Hondt: I think that’s where the government has to properly step in and do a tracer and find out where it is — where this rises. And I think that they have done that. They have an initiative now through the President’s initiative to look at insulin pricing. And I’m hoping that we can all work together; the organizations, the providers, the manufacturers of insulin, the PBMs and identify ways to save money on the ultimate buyer at the end of the line. Nobody should be denied from a lifesaving drug, ever.

Freed: So, if you look to the future, how would diabetes education be delivered? I’m just thinking about it right now is that if we could require people to take a class to lower their taxes by 10%, they could do it on their phones. What are your thoughts?

D’Hondt: So, there were thoughts. We’ve had some discussions as we’re doing a visioning piece for the future of the diabetes educator. We’ve talked to providers. We’ve talked to some of the stakeholders. It was kind of apparent partway through that some people thought, “Well, if technology can deliver all of this, if you can put our curriculum into an app, then what would be the need for an educator.” The thing is that the educator puts the human touch on where technology can’t. We can interpret patients’ feelings. We can look at their body language. A computer can’t feel that yet. I think people still need that person who’s helping them, that one-on-one who understands their needs, can identify their needs, someone that they feel comfortable talking to. You can’t talk to a phone. You can’t talk to an app. You can talk through it, but you can’t talk to it and get empathy and sympathy. And I think that’s what our patients need is to be understood, for us to help them navigate, to help them understand where the barriers are to learning and to access. And I think that’s what we do best is help them navigate.

Freed: If you put the word diabetes into Google, you’ll get 36 million hits within 12 seconds and 90% of that information is not accurate. And people are hit all the time on cable TV with the cure for diabetes for $29.95, and it’s really something that needs to be changed. And like you said, I think government needs to step in and make certain requirements for people and their health care. And eventually I’m sure it’ll be here, but it’s going to take a long time.

D’Hondt: I hope so.

Freed: Maybe you can give us a little idea about what AADE is doing about peer support and how that helps.

D’Hondt: So, Steve, as I mentioned earlier in the interview the patients spend very little time with the health care provider and most of their life is spent in the self-management arena. We realize that peer support and technology are important dynamics as far as giving them that support while they’re on their own. And we had a summit or a consensus conference with a group of educators and those from the diabetes online community, as they were referred to before, to see how we could work better together and how we can offer more support to the patient. And the outcome was that we got away from the term online communities and decided that they were actually peer support communities. We have peer support in the physical sense and we have online peer support. And that offers people the opportunity to reach out to their peers and get questions answered in their daily routines. Things that maybe the health care provider couldn’t answer, maybe they didn’t have access, it’s at a time when they don’t have access. Maybe they’re afraid to ask the health care provider but they’re more likely to ask a peer who has been through this and has had those experiences. And that’s an important dynamic of having that help you navigate diabetes on a day-to-day basis.

Freed: And maybe kind of give us a little idea of what this program which has a unique name, DANA, which is my daughter’s name, what it is? What is DANA?

D’Hondt: So, we realized at AADE that technology is playing a huge role in facilitating better care. It doesn’t replace the health care provider but it better enables them to provide care in different ways. So, what’s become confusing is the pace of technology is going so fast that we as health care providers can’t keep up with it. We decided to set up a one-stop shop for all the new technologies. So, we have buy-in from the technology providers and you’ll be able to go, and they’ll be like buying something on Amazon except you’ll be looking at different technologies. What’s available, you’ll be able to access through that portal, direct access to the manufacturer’s website to learn more about the technologies. So, you can stay up-to-date on what’s new, what’s out there, what’s in development, what’s the research is, what’s the evidence behind it is. We’ll have teaching modules to help you learn more about the uptake and utilization of technology to help your practice, how to incorporate these new technologies, what might be coming down the pipeline, and we also have an app review on that same DANA website that will help you recommend an app with confidence that it’s been vetted by AADE or our vendor to make sure that you can recommend it with confidence.