A Diabetes Educator Walks Us Through a TeleHealth Endo Appointment

With our country slowly heading back to our “new normal,” we will likely have to go back to our regularly scheduled lives, which includes being diligent about keeping up with all our routine doctor visits. It is even more important when living with diabetes to have annual eye appointments, physicals, dental appointments, and of course, our endo and diabetes educator appointments.

Since many are apprehensive about this new set up and wondering how exactly it will work, I thought it would be great to talk to Dawn, a nurse practitioner and certified diabetes educator who works in an endocrinologist office and have her walk us through the process and what we can expect.

Thank you, Dawn, for taking the time to talk to me today! How long have you been living with type 1 diabetes? 

24 years at the end of this month. 

Did living with diabetes play into your decision to become a CDE?

I had a great CDE in 1995 in a rural town which was unheard of. Then in college, I had a great nurse practitioner (NP) that I still look up to as a mentor for my practice. She talked to me like a person. She talked to me without pressure, shame, guilt, accusations and disappointment. She helped me come to terms with my diabetes and I will forever be in debt to her. I want to pass on that experience to other people living with diabetes.

How has your endocrinologist office responded to COVID-19? Have you closed down? How did you prepare for seeing your patients virtually?

We stopped seeing patients in the office at the end of March. We do still need labs so our lab is open but that significantly reduces foot traffic. We are only ordering labs that are necessary and will dictate current decisions. If they are not needed right now, then they can wait. We have two practice locations and staff are staying at one location. This way, if one office is quarantined we still have the other office to ensure patients have medical support.

We transitioned to virtual visits using the telehealth visit option within our EMR (electronic medical record) and we are using doxy.me as well. We are calling patients ahead of time to let them know about the change in the appointment and encouraging them to try to log in and make sure it works prior to their appointment. This would give you the chance to troubleshoot technical issues prior to your appointment.  We have had a few patients who still needed to be seen in person but almost all of our visits can be completed via telehealth.

I know many patients are curious about how an appointment like this will work. Is there anything the patient needs to do prior to the appointment? I know my son has an upcoming telehealth appointment and we had to download a certain app.

I would recommend as listed above making sure your means of communication works. Do a trial run at the location you plan to be at. If you will be at work during the call, make sure it works at work. If you are at home, then make sure it works at home. Will you use a computer or a smartphone? Do you know how to troubleshoot the speakers, video and microphone? Do you have a pump, continuous glucose monitor, or meter to download ahead of time? If you do, then get these downloaded at home prior to your appointment. Do a practice run a week ahead of time so if you need to call for help you have time to do so.

Having blood sugar readings and pump downloads ahead of time has streamlined my practice. I can view them prior to the appointment and focus on key items to make the appointment more productive. We are encouraging all patients to download at home, but we have made the exception for a few (elderly) to come and download at the office.

Can you walk us through what to expect during the appointment?

My wonderful medical assistants (Ariel, Tonya, and Whitney) have been calling patients to go over medications, any new changes to medical history just before the appointment and checking to make sure the telehealth app or doxy.me is working. Hopefully, I have already reviewed blood glucose logs and pump downloads ahead of time. If not, I will encourage the patient to get that for me.

What are some of the drawbacks of a telehealth appointment? I know my endocrinologist usually examines my thyroid, heart, etc. How will the doctor be able to check vitals as well as other routine measures? 

Yes, not being able to physically assess a patient sometimes is tough. However, if I am concerned enough that we need an in-person assessment ASAP, then they likely should have an urgent appointment with their primary care provider. If someone is complaining of an enlarged thyroid, with a keen eye, we can visualize that in most people via video. However, nothing replaces a hands-on assessment. We will see a patient in the office urgently if needed.

Do you find that overall providers have more or less time to spend with their patients this way?

When we have data (CGM/BG/Pump/labs) there is more time for providers to spend having meaningful conversations with patients. This streamlines appointments.

As a medical professional, how are you finding the telehealth appointments? What do you find most challenging?

  • When I have the data prior to an appointment, I love telehealth. I also love that I can go over reports with the patient and educate them on what I am seeing.
  • The most challenging part is obtaining data prior to the appointment. My medical assistant makes 2-3 calls prior to an appointment trying to prepare each patient. If I don’t have data, then essentially we are making an educated guess about what medications need to change.
  • For example, a patient can complain of afternoon hypoglycemia. However, it could be a reduction in basal insulin needs, overcorrection of pre-lunch blood glucose, or a too aggressive carb ratio. If we do not have data (CGM/BG/Pump) information, there is no way to tell for sure. So we ask questions around and around to try to figure out the most likely scenario but if we are wrong, you may have less hypoglycemia but BG will run higher. I know I do not want my provider to essentially guess at what needs to change.
  • Another example is a high A1c and the provider increasing the long-lasting insulin (basal) or basal rates unnecessarily causing low blood sugar in the middle of the night. I see this often when providers are grasping at straws trying to improve blood sugar control. When the real reason may be significant after-meal blood sugar spikes.

For someone who is unfamiliar with Zoom and other related apps, it may present a novel challenge. Have you found patients are having trouble with the new set up? Do you provide explicit directions on how to get set up for the appointment?

Most patients who have reliable internet access and have a smartphone or computer with a camera the platforms we use work beautifully. Doxy.me just requires the patient to click on the link we provide in an email. Click and then wait for me to start the appointment.

What do you think the patients will find the most pleasant about the virtual appointment? And what about the worst aspect?

The best part is that you can sign on from anywhere with cellular service or Wi-Fi. So your time away from work or other commitments is minimal. The worst part is that you are still at work or home and there are often other distractions. For example, if children or a dog are disrupting the appointment, this can be distracting and cause the appointment to take longer. It is also not a good idea to have an appointment while driving.

What can you tell us about privacy compliance? How can patients be sure their information is safe?

When using the Healow app or Doxy.me, the voice and video access is encrypted, keeping the visit private. The actual video does not access the patient chart in any way.

Looking forward, what do you think our medical system will look like after COVID-19? What about in 10 years?

I have no idea. I have learned to never assume anything in medicine because just when we think something will happen, the opposite occurs. I am hoping this opens doors allowing more rural telemedicine. This will provide medical care, especially those with chronic diseases, living in rural areas that travel 1, 2, or sometimes 3 hours for appointments. Historically, telehealth is not covered by insurance and the cost falls onto the patient. This hopefully will allow for proper insurance billing of these appointments to be more cost-effective and convenient.

Thank you so much, Dawn, for taking the time to walk us through what a telehealth appointment will look like. I have had two so far and they both went successfully! Best of luck and thank you for what you do!

Source: diabetesdaily.com

New COVID-19 Medicare Funding for Telehealth in Australia

By Rachael Baker

COVID-19 is proving to be an extreme and unparalleled time for healthcare services across the globe. Credentialled Diabetes Educators (CDEs) are not exempt from this rapidly changing landscape and multiple shifts are occurring in the way we now provide care. Changes to funding models are being welcomed by CDEs with open arms.

Telehealth is by no means a new concept for patients living with diabetes in Australia, and CDEs have been advocating to endorse telehealth to be an equitable means of service delivery for quite some time. Telehealth is often an integral component of care for a person’s diabetes management; however, never before have patients been able to claim Medicare rebates on these services, until now.

Easier Access, More Convenience

Prior to the COVID-19 funding, telehealth already enabled many Australian

s living with diabetes, especially in rural and remote areas, to have access to up-to-date, specialist education and diabetes technology provided by CDEs. Diabetes is a chronic condition that necessitates a person to attend frequent appointments to a range of healthcare professionals across the multidisciplinary team, including: General Practitioner (GP), CDE, Endocrinologist, Dietician, Podiatrist, Psychologist, Optometrist, along with other specialist clinicians. Juggling life, and diabetes and attending these appointments can prove difficult at the best of times.

Telehealth consults eradicate time spent on the sometimes long journeys traveling to a CDE appointment, time taken off work (especially if telehealth consults are provided outside of business hours), along with the difficulty of finding someone to mind the kids and the common struggle of parking. While face to face consults are still imperative, especially for new diagnosis and starting on insulin pump therapy, telehealth services have anecdotally proven to have high attendance rates and result in patients feeling well supported, leading to greater health outcomes, both short and long term.

Rebatable Telehealth Appointments

As we see ourselves voyaging through the uncharted waters of this pandemic, abiding by Australian Government guidelines in line with social distancing and essential interactions only, it is a relief that patients will be able to have critical access to CDEs via Medicare rebatable telehealth appointments. While we are navigating the finer details (see link for legislation), it looks like this will be equivalent to current face to face Medicare rebates, equating to $53.80 per consult for patients who have a shared care plan, or a GP Management Plan and Team Care Arrangements, or if they are a resident of an RACF and have a multidisciplinary care plan.

CDEs are the front line when it comes to providing education to patients with diabetes to safely and effectively manage their blood glucose levels (BGLs), optimize their health and wellbeing, but also assisting people with diabetes to safely navigate their blood glucose levels and ketones during sick days. Now more than ever, as our acute healthcare services become overwhelmed, it is vital that we support people living with diabetes to stay safe and well, avoiding preventable Emergency Department presentations and hospital admissions. We also need to come together to support tertiary diabetes services, as they redirect medical and nursing staff to emergency and acute inpatient areas to meet the demand of COVID-19 patients.

Telehealth: A Service Innovation

Living with type 1 diabetes myself, I strongly stand by the notion that patients find this innovative means of service delivery extremely beneficial. It focuses on the needs of an individual and discovers a way to make diabetes management fit into people’s lives with greater ease. With today’s technology, telehealth platforms are incredibly easy to use and patients are able to attend their telehealth appointment using their smart mobile phone.

Given the current climate, telehealth is quickly becoming the standard or the ‘norm’ for a lot of outpatient services. As I have already mentioned, face to face consultations with CDEs will always be essential, nevertheless, telehealth appointments certainly have a broad and practical range of opportunities for use. During this time, telehealth consults are not merely an option, but in fact, the only option to stay engaged with their regular CDE appointments and receive the imperative support and guidance they require.

This is a milestone worth celebrating, and as we are being forced to reflect upon what is really necessary in our individual lives, for those living with diabetes, CDEs certainly fit the bill, and the Australian Government thinks so too. CDEs have a significant impact on people living with diabetes; as a patient and a clinician, I have experienced this from both sides.

I would like to thank Diabetes Australia, the Juvenile Diabetes Research Foundation (JDRF), the Australia Diabetes Educators Association (ADEA), Diabetes QLD and NSW ACT, and most importantly our diabetes community whom are themselves, their loved ones or family members, living with diabetes. I am incredibly passionate about telehealth, and with this funding set to kick in on March 30, 2020, my next question will be whether the cease date on September 30, 2020 will be negotiable, as inevitably people with diabetes adapt to a new way of seeing their CDE.

Stay home and stay safe.

About the Author

Rachael Baker is Credentialled Diabetes Educator (CDE, BN) and Clinical Nurse Specialist at Macintyre Health. You can follow her or her company on Instagram for tips.

Source: diabetesdaily.com

How to Optimize Telehealth During COVID-19

COVID-19 has changed the landscape of many things: job security, the stock market, access to health insurance, and the capacity of the healthcare system as a whole. Hospitals in the United States are currently at or exceeding capacity in their emergency departments, and there is a growing need for and shortage of beds, personal protective equipment (like gloves and masks), and healthy physicians. One way states are trying to save capacity for their sick COVID-19 patients is to ban elective surgeries and routine appointments for a period of time, to save space, time, energy, and resources for our sickest patients.

Unfortunately, when you live with diabetes, you usually need to see your physician (typically an endocrinologist) several times a year for HbA1c blood work, refills on prescriptions, and to adjust dosing requirements with changes in diet, exercise, and hormonal changes (brought on by life stage, stress, or pregnancy). What some offices are doing to make space for both is to offer telehealth appointments.

What Is Telehealth?

Telehealth is the distribution of healthcare services via telecommunication technologies, like phones and computers. It allows long-distance patient and physician communication, care (such as check-ups), health advice, important reminders, monitoring of conditions, changes to therapy (like adjusting insulin doses), and can even allow for remote admissions to hospitals.

Who Can Utilize Telehealth?

Most private health insurers will cover telehealth appointments, although there is no set standard for covering this kind of care.

A total of 48 state Medicaid programs cover telehealth, which can prove beneficial in rural settings when a lack of transportation, lack of patient mobility (such as a disability), or shortage of local or regional staff restrict access to care. In these instances, telehealth services can bridge that gap. The Medicare Fee-For-Service Program will cover telehealth from originating sites (like a hospital or healthcare facility) to patients who live in rural areas, Health Professional Shortage Areas, or a specified county outside of a metro area.

In the United States, over 76% of hospitals utilize telehealth to better serve their patients, yet you may still have never heard of this service! Additionally, 35 states and DC have enacted “parity” laws, which require health insurers to cover services provided via telehealth the same way (and the same amount) they would reimburse for services provided in person.

If your health insurance company doesn’t cover telehealth services for you and you need advice from your doctor, most physicians are willing to accept self-pay for the service. Some patients are willing to pay out of pocket for the convenience of getting their care via telehealth, although that’s not reasonable to expect for the general population.

Improving Access to Telehealth During COVID-19

In response to the COVID-19 outbreak (and under President Trump’s National Emergency Declaration), the Centers for Medicare & Medicaid Services (CMS) expanded access to Medicare telehealth so that patients can receive a wider range of services via the platform. The benefit is being expanded for all Medicare beneficiaries under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Acts. These steps are to ensure that all Americans, especially older Americans who are more susceptible to severe complications if they contract the virus, are aware and can take advantage of more accessible healthcare benefits, while socially distancing themselves to prevent the spread of the virus.

According to CMS, “Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.” An expanded range of providers such as traditional doctors, but also nurse practitioners, clinical psychologists, and licensed clinical social workers will now be able to offer telehealth to patients.

The waiver also provides flexibility for physician groups to reduce or completely waive copayments and cost-sharing for telehealth visits for Medicare patients. Additionally, under this waiver, telehealth visits are considered the same as in-person visits, and are paid at the same rate as traditional, in-person visits.

Which Types of Providers Typically Use Telehealth?

Typical telehealth services are those rendered by physicians (including endocrinologists!), nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, licensed clinical social workers, registered dietitians, and nutritionists. This, of course, can vary by state and state law.

How Do I Get Started?

If you need to see your physician or endocrinologist, and want to try telehealth, call their office and see if they currently take advantage of such technology. If they do, they might have you download a compatible, HIPAA compliant platform for chats and video conferencing, or you may even be able to use your own telephone and FaceTime or Skype. It’s important to also check with your health insurance company to make sure they cover for such services, so you aren’t stuck paying out of pocket, which can quickly become prohibitively expensive.

The Future of Telehealth

Despite some reimbursement and HIPAA challenges, there are incredible benefits to increasing the utilization of telehealth to meet the needs of a growing and aging population. Also, with COVID19 preventing many physicians from seeing patients in-person, and high-risk groups like those living with diabetes warned to stay home, telehealth makes the most sense to both protect patients while concurrently meeting their healthcare needs. The convenience of care, improved access for both physicians and patients, efficiency of no commuting time or waiting room eunni, and time savings for everyone make telehealth the ideal choice for patients and physicians alike, and we should see these trends continue into the future.

Have you utilized telehealth to help manage your diabetes care? What did and didn’t you like about the experience? Share this post and comment below, we love to hear your stories!

Source: diabetesdaily.com

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