How to Use Telehealth in Diabetes Management

Case Study

Mr. Gameche is a 58-year-old man First Nations man who lives in a remote community served by three permanent nurses and locum family physicians who visit for three days per month. He was recently hospitalized for diverticulitis and was seen by a consulting endocrinologist to help in the management of his Type II diabetes, which has been poorly controlled for the past three years despite increasing doses of oral medications. Mr. Gameche had been previously reluctant to start insulin, but during his hospitalization he achieved good understanding of insulin use and received appropriate education by a diabetes nurse educator and dietitian. He is now ready for discharge back to his community, and he asks how his diabetes will be managed in the future. Mr. Gameche’s community is a six-hour drive from the nearest specialist services, which include internal medicine but no dedicated diabetes resources. At the time of discharge, he is taking insulin glargine as basal and aspart as bolus insulin with his meals.

Which of the following option(s) would you recommend as the optimal follow-up plan for Mr. Gameche’s diabetes care over the next six months?

Monthly 90-minute visits to the diabetes clinic in the hospital he was discharged from.
Weekly phone calls from the hospital diabetes nurse educator to learn the patient’s self-reported health status and advise him on insulin adjustments.
Detailed written instructions from the endocrinologist to the local nurse regarding how to titrate the patient’s insulin doses, along with a phone number to call for help.
Telehealth appointments (15-30 minutes each) every 2 to 4 weeks with the endocrinologist and/or diabetes education team, involving both the patient and his local nurse.
Follow-up as needed by the family physicians visiting the patient’s community.
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The option you selected involves substantial travel cost and is unlikely to be sustainable for the patient. It also provides no direct link between consultation services and the patient’s local care providers. If problems arise between the clinic appointments, the local nurse may not have adequate support. Option #2 does not involve a local health care provider, so it is difficult to review physical parameters (weight, blood pressure), recent lab results, or other important developments that may be documented on the local medical chart.
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The option you selected does not involve a local health care provider, so it is difficult to review physical parameters (weight, blood pressure), recent lab results, or other important developments that may be documented on the local medical chart.
Try another option.

The option you selected includes advance written information, cannot foresee every possible situation that could arise in the patient’s care. Insulin adjustment is part of the patient’s diabetes-related care, but insulin titration alone will not address lifestyle measures, vascular risk reduction, or monitoring for complications. In some situations, it may be asking the nurse to practice beyond his/her level of expertise.
Try another option.

This is the optimal follow-up plan for Mr. Gameche. It provides an opportunity for the experts to review multiple aspects of the patient’s care, including measured lab and physical parameters, on a regular basis. It also provides a direct link between the patient’s specialist team and the local nurse who provides continuity of care. Even if the local nurse is not initially familiar with the patient’s insulin regimen, he/she will have the opportunity to ask questions and build a greater degree of comfort with the patient’s medications and care plan.
Click on the other options above to see why they are not recommended.

The option you selected does not provide the patient with continuity of care, and deprives him of the opportunity for ongoing specialist input into his care at a time when he is vulnerable (immediately following hospitalization and initiation of insulin). He may receive different types of advice from different physicians visiting his community, and the nurse (who alone can provide on-site continuity) is not brought into the care plan.
Try another option.

What is Telehealth?

Telehealth is the provision of medical care between the patient and the care provider without an in-person meeting, and can involve a telephone conversation or web-based appointment. It may be synchronous (as in the example above), involving real-time communication between the patient and care team with the assistance of technology to overcome barriers to access. Or it may be asynchronous, as in the case of a glucometer that automatically sends glucose monitoring information to a nurse manager (who can then recommend adjustments in medications via email or another means).

Telehealth can be used to improve access to expert diabetes care – either for housebound patients or for individuals in remote communities. Videoconferencing can achieve cost reduction for both patients and care providers, and can also reduce the number of unscheduled visits for chronic disease. Asynchronous (e.g. Web-based) interaction between patients and care providers can achieve improved self-management and clinical parameters, but this type of telehealth may also be associated with increased time demands on physicians or diabetes educators.1

The 2018 Diabetes Canada Clinical Practice Guidelines recommend the use of telehealth as part of a disease management program to:

  1. Improve self-management in underserviced communities (Grade B, Level 2)
  2. Facilitate consultation with specialized teams as part of a shared-care model (Grade A, Level 1A)
  3. Improve clinical outcomes in type 2 diabetes, including a decrease in A1C, an increase in quality of care (i.e. guideline adherence), a decrease in health service use and cost, and an increase in patient satisfaction and knowledge (Grade A, Level 1A)
  4. Improve glycemic and CV risk factor control in type 1 and type 2 diabetes (Grade A, Level 1)

Telehealth between a diabetes team and a remote patient should ideally involve the patient’s local care provider. This individual can often provide laboratory or chart data that would otherwise be inaccessible to the specialized team; he/she can also provide feedback on whether the diabetes expert’s recommendations are likely to be effective given the reality of the community’s resources. A telehealth meeting of 30 minutes is often adequate to craft (or revise) a diabetes management strategy that includes input from the patient, the expert team, and the local care provider.Fee codes in various provinces and territories provide appropriate compensation for clinicians who use this technology to provide care to remote patients.

1 Verhoeven, Fenne et al. Asynchronous and Synchronous Teleconsultation for Diabetes Care: A Systematic Literature Review. Journal of Diabetes Science and Technology. 2010;4(3):666-681.

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