COMPREHENSIVE DIABETIC CARE
GOALS IN TREATMENT OF PATIENTS
Our goals in treatment of patients with diabetes can always be reviewed by two perspectives.
Management of diabetes control, which includes prescription of medication as well as medical nutritional therapy and exercise regimen to get patients’ diabetes to goal with an A1 C of 6.5% or lower.
The other important goal that we always keep in mind is prevention of complications that is why at every visit, presence of complications is evaluated and monitored to ensure that existing complications are not worsening or new complications are not developing. Once any complication is identified, patients are treated appropriately to avoid any permanent damage from these complications.
CONSULT FOR DIABETES TREATMENT
Patients may be referred in by their primary care physicians or patients may come in on their own for evaluation of their diabetes state as well as treatment recommendations.
We are very experienced in treatment of diabetes and adept at instituting therapies to get patients diabetes control to goal to prevent complications. Once patients’ diabetes is not controlled or difficult to control, the primary care physicians or other physicians that are seeing patients, may refer patients to our care to evaluate and assess their status of their diabetes and to treat them to goal.
This consultation can be one time visit where patients are assessed and report/assessment is given to the primary care physicians as well as patients to adjust treatment to control patients’ blood glucose levels and if preferred by the primary care, patients can be fol - lowed up at the center for treatment and management of their diabetes.
CONSULT ON INSULIN TREATMENT
Many patients in the course of their diabetes are recommended to start taking insulin. We are able to consult on patients for their primary care physicians or for patients themselves to assess if need for insulin therapy is present and also recommend the kind and dose of insulin therapy.
Patients can learn how to administer insulin and to adjust treatment with insulin based on pattern recognition, which is taught to patients by our educators.
For this consultation, please call the office or ask for an appointment through the website or by E-mail.
Services for treatment of diabetes range from one time visit to assess the state of diabetes control and complications and need for treatment adjustment to ongoing monitoring and treatment of diabetes.
In addition, we have specific services to meet needs of patients who have a new diagnosis of diabetes. Patients who develop type-I diabetes are considered to be in a state of emergency/urgency where care needs to be delivered to these patients, however most outpatient facilities do not have the breadth of experience and services to provide the services to a new onset diabetes patient and most patients end up in the hospital. We have developed a plan of care for patients who develop new onset diabetes and are cared for at our center as outpatients.
In addition to these services, we offer state of the art service with insulin pumps where all brands of bumps are used. In addition personal glucose monitors are also prescribed and patients are trained on their use.
As far as diabetes education services are concerned, we offer weekly comprehensive diabetes classes for patients with type-II diabetes and a quarterly class, which is specifically geared towards patients with juvenile/type-I diabetes.
We also offer a daily walk-in service for patients who want to learn how to monitor their blood glucose and/or inject insulin. This is a complimentary session to all attendees.
ANNUAL PREVENTIVE PHYSICAL EXAMINATION
Patients who have insurance coverage of annual physical examination and have diabetes can have their annual physicals at the Center.
During the annual preventive physical examination status of diabetes is assessed and therapy is recommended.
Symptoms of neuropathy/nerve damage, are numbness, tingling, or burning sensation to the feet as well as cramping of the legs and feet.
These symptoms are assessed during physical examination To evaluate the severity of nerve damage, formal nerve conduction studies are done at the clinic where the functioning capacity of the nerves is assessed.
This test determines the exact function of the nerves, which can be monitored on an annual basis to see if any change or deterioration is occurring in the nerve function as this is a complication of diabetes.
This test can be done as part of annual diabetes, physical examination or it can be done at any time when symptoms develop by sending an appointment request with the clinic by calling or sending an E-mail.
This test is only offered to our existing established clinic patients or for patients who are undergoing an annual physical examination.
As part of our annual physical following routine labs that are obtained:
Kidney function test
Thyroid functions tests
Kidney function evaluation with urine study that checks for protein in urine.
These tests are also done on patients who follow up at the A.M. Diabetes and Endocrinology Center for their routine maintenance of diabetes.
These tests are covered by insurance as part of monitoring and treatment of their diabetes.
If these tests are required by patients who do not have insurance coverage, please call the billing department to check for the cost of these tests.
ANNUAL DIABETES PHYSICAL
For patients who have type-I or type-II diabetes, this service offers a comprehensive annual examination where the status of diabetes control as well as status of complications is evaluated and treatment plan established.
After evaluation of diabetes control, treatment modification is recommended for patients whose blood glucose is not at control (that is A1C level is above 7%). Treatment plan is established and medication change is recommended to get the diabetes control to goal.
For evaluation of complications, physical examination is done to look for presence or absence of neurological damage/(neuropathy), as well as vascular insufficiency/inadequacy.
Additional testing done are:
- Screening test for circulation.
- EKG to monitor cardiac status is done.
- Eye exam is done where a photograph of the retina is taken to look for any damage/eye complications related to diabetes.
This examination is recommended for patients who have stable diabetes control and want to monitor development of complications and have this done once a year.
For patients who have diabetes and related complications, this monitoring/examination ensures that these complications are not worsening and/or stable.
This examination can be scheduled at any time by calling the clinic or sending an E-mail to scheduling at amdiabetes.net or contacting us through the website.
As part of the monitoring of patients with diabetes, it is recommended under American Diabetes Association guidelines that annual eye exams be done on patients with diabetes whereas presence of retinopathy/eye damage is checked.
As diabetes is the leading cause of blindness in our country, this monitoring exam is extremely essential as treatment can be offered once any eye damage is detected.
This test is done by fundus photography; the test is read under strict protocols. Once we have the results of the eye exam and if there is presence of any retinopathy/eye damage, we refer our patients to our eye care specialists for further treatment and evaluation.
Foot exam is a very integral part of our evaluation of our patients.
Diabetes can cause damage to the feet by neuropathy(nerve damage) and circulation damage. The leading cause of toe, foot and leg amputation is from uncontrolled diabetes.
During our examination, attention is paid to the vascular status of the foot as well as neurological status of the foot, it is important to evaluate this as any damage to the nerves or circulation can lead to development of pressure points, sores, ulcers, which can lead to infections, which may invade the soft tissue or the bones and eventually lead to amputation.
Foot examination is done to make sure that the circulation and neurological supply to the foot is intact and if any abnormality is detected, then proper diabetic footwear is recommended and further circulation evaluation is done to see if any circulation damage can be reversed.
Screening For Circulation
The screening for circulation is done by ABI (Ankle Brachial Index) methodology where blood pressure is monitored in the arms as well as legs simultaneously and this test is able to screen patients that may have damage to the circulation to the legs and feet and identify patients that need further testing.
This test is routinely done during office visits as well as annual diabetic physicals. This test can be requested if patients are experiencing any pain in their legs specially on walking to make sure that symptom is not related to circulation problems.
Circulation screening can be scheduled as an independent test by existin patients by contacting the clinic or requesting an appointment via the website or E-mail.
Hgb A1C is a test that determines the average blood glucose level that a person had over the proceeding 90 days. This test is available at our laboratory, however, it is also performed on patients that are seen in the clinic at the time that they are seen and is called point of clear A1C test.
Point of clear A1C test yields the results in under 10 minutes, so that at the time of assessment of patients, it is an important test to help determine the need for change in treatment.
This test is also recommended for patients who have prediabetes and/or insulin resistance, so that the level of their blood glucose or period of time can be assessed and their disease status monitored.
Electrocardiograms are done on patients with diabetes annually as some patients with diabetes can experience heart trouble and/or heart attack without experiencing typical chest pain.
Routine Maintenance of Diabetes Care:
Patients with diabetes who seek their care for diabetes at the center are followed regularly and the interval of followup is determined by the degree of diabetes control and may range from few weeks to six months in between visits. Patients are monitored and medications for diabetes adjusted and prescribed in addition medications for kidney protection/blood pressure treatment as well as cholesterol treatments are prescribed. The patient’s Hgb A1C levels are monitored at regular intervals to assess the degree of diabetes control.
Where needed treatment is adjusted and patients are offered routine nutritional counseling by our nutritionists as well as diabetes educators, so that we can control diabetes to goal and prevent complications.
If you want to have your diabetes monitored and managed here at the center, please call for an appointment or send an E-mail through the website.
Patients who are followed for the routine maintenance for diabetes are assigned primary care managers, which are nurse practitioners and they are under direct and close supervision of the physicians/endocrinologist. Patients get to see the endocrinologist at every visit, however for any need in between visits or any issue that arises, they have their primary care managers to reach via structured system, so that there is easy access to care and all concerns and issues for patients are answered in a timely fashion and to their satisfaction.
Patients who are followed for routine maintenance of care have their prescriptions filled and blood tests monitored during their visit to the clinic at regular intervals.
In addition, we offer annual flu vaccines for our patients as these are important vaccinations to prevent influenza infection, which can be more severe in patients with diabetes. In addition, for patients with diabetes that are followed at the clinic regularly pneumonia vaccines, shingles vaccination are also recommended.
Patients are also offered exercise programs and specific treatment/exercise plan is recommended based on individual needs.
NEW DIAGNOSIS/ONSET OF DIABETES
If you are diagnosed with diabetes, we offer services for you to stabilize and treat your diabetes.
Type-I Diabetes/Juvenile Diabetes:
When patients are diagnosed with type-I diabetes, they are faced with emergent situation where treatment needs to be instituted urgently to prevent development of acidosis, which can be a very serious situation.
Traditionally, patients who develop type-I diabetes are admitted to the hospital at the time of diagnosis, where they stay for 3-5 days to learn the treatment of type-I diabetes and learn about the pathophysiology of diabetes and monitoring and treatment of the condition as outpatient.
Because of our experience in treatment of diabetes and the multidisciplinary approach where we have diabetes educators and dietitians to help our endocrinologist and nurse practitioners to take care of our patients, we are able to take care of these patients on an outpatient basis.
Once patients are diagnosed with type-I diabetes, they are seen as soon as we are informed of a patient either by their primary care physician or by the patients themselves. We have a special program where we bring patients into the office immediately and assess the patients with blood glucose level, vital sign monitoring, as well as Hgb A1C testing, which is done on site. Thereafter if needed insulin is administered to these patients under observation and treatment plan is instituted.
If patients is dehydrated and not stable to be treated at home, they are sent for admission to the hospital, however patients who are not extremely ill or not very dehydrated; they are treated in the clinic and treatment plan is instituted, which typically is a treatment plan for the following 24-48 hours as patients are seen on at least three consecutive days in order to stabilize their new onset diabetes and proper treatment is instituted.
On day 1:
There is initial evaluation, Hgb A1C testing, blood glucose monitoring, insulin treatment if needed as well as basic diabetes education given to the patient and the family and monitoring and treatment of their diabetes is planned for the next 24 hours.
on second day the patients return, their clinical status is reassessed and treatment is modified based on their blood glucose values and response to initial treatment. Additional diabetes education is afforded to the patient as well as family and treatment for the next 24 hours instituted. Part of prescribed insulin is administered in the clinic and part of which is to be administered by the patient and family at home, however the family and patiet are taught administration of insulin.
Patients return on third day and response to treatment is evaluated and treatment is adjusted as needed. Patient,s and family’s needs are assessed and further education is reviewed where type of food intake, fluid intake, and a meal planning is done.
After initial three days, if the providers are satisfied, patients are brought back to the clinic after 2-3 days interval or one week’s interval depending on their clinical status and understanding of the disease process and comfort in handling of patient’s diabetes at home.
After the first week, the patient is scheduled for formal diabetes/training as well as long- term treatment plan is instituted.
Typically, the new onset of type-I diabetes is life changing experience for the whole family and new way of eating treatment of diabetes and home routine has to be established. We walk our patients through each one of these steps, which ultimately leads to long-term success in optimal treatment of diabetes and prevention of complications.
Patients who have a new diagnosis/onset of type-II diabetes are also seen in the clinic the same day or within 24 hours depending on their clinical situation and status. Patients are evaluated and based on clinical examination and laboratory testing treatment is planned.
Initial plan of care is administered and medications if needed are prescribed. Thereafter patients are scheduled to attend the comprehensive diabetes class where diagnosis of diabetes and treatment of diabetes as well as change in lifestyle is reviewed in detail, according to American Diabetes Association guidelines.
We have found that taking care of patients as soon as they find out their diagnosis, keeps patients out of the hospital and lead to prompt institution of therapy without any delay in care.
SCHOOL FORMS FOR PATIENTS WITH DIABETES
For school going patients who are on multiple daily injections of insulin or on insulin pump therapy, it is recommended that they make an appointment during summer break with our diabetes educators, so that their school forms can be completed and sent to the proper schools before the start of school year, this ensures appropriate information to be shared with the schools to ensure a proper management and treatment of diabetes in the school.
Personal glucose monitors
There have been significant advances in use of personal continuous glucose monitors. These devices have a small filament, which is inserted under the skin from where the device is able to measure and monitor the glucose levels. These glucose levels are transmitted to a wireless monitor, which displays the blood glucose levels continuously for as long as the monitor is functioning properly and the patient is wearing it properly.
Most sensors are approved for use for seven days hence sensor has to be changed every seven days.
We are well-versed in use of personal continuous glucose monitoring sensors (CGMs) and are able to train patients on the use of personal sensor and prescribe these sensors.
For review of personal glucose sensors and to see if you benefit from this treatment, please call and make an appointment with one of our diabetes educators or providers.
Personal sensors and pump combination:
At present, the Medtronic insulin pump communicates directly with the Medtronic glucose sensor, which transmits blood glucose levels to the pump.
The 530G system, which was approved by FDA for use in September 2013 where the pump therapy is sensor augmented. This means that the pump suspends delivering insulin if the blood glucose falls below a certain level, and prevents severe hypoglycemia in patients using the system.
We have great deal of experience in using the sensor augmented pump therapy and all of our staff are able to help patients who are on it and to educate people who want to understand and start this system.
For patients who are on treatment with insulin for their diabetes and have fluctuating blood glucose levels, accurate treatment adjustment is at time done through glucose monitoring via glucose sensor that is inserted under the skin and monitors blood glucose level every 5 minuts as long as it is worn.
The glucose sensor is inserted under the skin and stays there for 5-7 days. During this time the sensor monitors blood glucose levels continuously. Once the sensor is removed and downloaded; the data it provide, help the providers to more accurately adjust treatment.
In addition, the information that is gathered by the CGM, lets patients know the effect of different foods and activity on the blood glucose levels and is a great tool in modifying behavior as well as treatment to get to adequately treated diabetes.
These monitors as recommended for use by the providers and patients are placed on these monitors during the clinic visit. They drop the sensor back after they have worn it for the prescribed time period. The data from the sensor is downloaded and patients thereafter come back to sit down with the diabetes educator to review the tracing and the provider at that time recommends a change in their treatment regimen to get the blood glucose to optimal control.