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Overcoming Obstacles to Diabetes Care

After many years of controlling her type 2 diabetes with oral medication, 92-year-old VNSNY CHOICE MLTC member Manuela* was recently started on daily insulin injections. But with her advanced dementia, she couldn’t administer the shots herself. So Christina F., her CHOICE Care Coordinator, reached out to Yael R., a VNSNY Clinical Support Manager, certified diabetes educator, and diabetes nurse specialist.

“Yael is invaluable because of her vast range of diabetes expertise,” explains Christina. “No one is better at assessing patients and coming up with a diabetes regimen suitable for their needs.”

Manuela’s switch from oral medication to injectable insulin is a common occurrence, says Yael, who’s worked with VNSNY for 22 years and has been a diabetes specialist and educator since 2004. “Most people can manage their type 2 diabetes with oral medications for the first eight to ten years after they’ve been diagnosed. After a decade, though, most will have to start using insulin because of the disease’s progressive nature.”

Insulin therapy comes with a unique set of challenges, however. Many patients, as well as their family and caregivers, have an aversion to needles. Some patients also suffer from impaired dexterity due to conditions like Parkinson’s, MS, or ALS, making self-injection impossible. Plus, insulin needs to be administered at the same time every day, which can be a challenge for people with irregular caregiver schedules.

“Whatever the obstacles, we work around them,” says Yael. “I’ll review the clinical notes and come up with a recommendation that the nurse then presents to the doctor.” If there’s still no improvement after a few visits, she will accompany the nurse on a patient call to identify the issues that are impeding treatment. One patient wasn’t taking his insulin because the syringe was too difficult for him to operate and his insurance didn’t cover insulin pens, which deliver the dialed dosage at the push of a button. Yael discovered that his insurer would pay for a different brand of pen, and got his doctor to change the prescription.

The insulin pens are a lifesaver, notes Yael. Occupational therapy can also be helpful for patients with mild dexterity issues. Things get trickier with patients who have dementia, since home health aides aren’t allowed to dose the insulin—meaning someone else has to be recruited to administer the shots. In Manuela’s case, Yael set up a meeting with a friend who lives nearby and visits her daily. “We asked the friend if she would be willing to commit to giving Manuela injections each day using an insulin pen,” Yael recalls, “and she agreed.”

As a diabetes educator, Yael also presents diabetes information at clinical team meetings and meets with nurses one-on-one for diabetes-education coaching sessions. “Approximately one-third of our patients have diabetes in addition to their primary diagnosis,” says Yael. “This means our nurses are treating thousands of patients with diabetes on any given day.” When a nurse or care coordinator requests a home visit, Yael will demonstrate to the nurse how to educate the household—including the patient, family caregivers, and home health aides—on diabetes care. She first assesses the patient’s needs and abilities and comes up with a care plan, then goes over any medications the patient may be taking (including oral diabetes drugs) and gives tips on diet, exercise, and how to monitor glucose levels and overall health indicators.

The ultimate goal is always to help patients and their caregivers self-manage their condition. “We’re really there to teach them how to take care of themselves,” Yael explains. For all her many years of involvement with national diabetes education and home health care, Yael never takes her patients’ experiences for granted. “I’m always honored that they let us work with them in their homes and help them at their most vulnerable,” she says. “I consider it a privilege.”

* The patient’s name has been changed for privacy.