Thank you. Now let's talk about some specific strategies, both for patients and providers as well as systems and even some practice integration tips. But the patient-centered communications are the most important strategy for us as clinicians and educators. Patient-centered decision-making is at the center of all we do. People with diabetes have to be engaged in their care. They have to feel like part of the team. And trust, building that trust, is really a very important part of that. In fact, there's a fair amount of data telling us that patients reported more beneficial health behaviors, fewer symptoms, higher quality of life, and greater patient satisfaction when they had higher trust in their health care providers. Social determinants of health are a list of things that we need to be conscious of. Fifty to sixty percent of social determinants of health are responsible for success. That's how we'll be able to problem-solve barriers. But some barriers, of course, are very common. And in our offices, for example, we may see patients have cost as an issue. And so to increase access, one of the strategies I've used is to call or have the MA call the pharmacy and verify, first of all, that they received the prescription. Then beg them, if you have to, to run the prescription and tell us what will be the out-of-pocket cost. Then your patient knows that before they ever leave your office. You may have gotten one that's not the right one on the formulary. So you'll know that before the patient ever gets to the pharmacy, is hit with that, here you go, $1,000 please. That person will never take the medication at that out-of-pocket cost. Another really simple strategy is to be sure the patient practices with the demo pin, or if you have samples in your clinic, let them give the first injection. And it's always, oh, that's all there is to it. And so people don't know that, though, they build up fear until they actually do it. And then, of course, talking through the medication, taking it regularly, talking about how GLPs may reduce the need for insulin doses, may reduce the dosage amount, may delay the onset for the need for insulin. As you're starting your conversation with people about initiating GLPs, here's some sample questions that may really help get to the heart of some of the issues, the barriers that people have. Something as simple as what worries do you have about diabetes? Are you worried about your weight? Have you had trouble with weight loss? What are your main concerns about starting this medication? Any worries about cost, side effects? And so as you look down these questions, they're all very good conversation starters. But the last bullet, really, after you've had some conversation, helps drill down on whether or not you've helped address everything. On a scale of 1 to 10, how confident are you that you could do this? You could administer the self-injection. You could get this medication. And that bit of motivational interviewing helps you uncover additional barriers that you may have missed. But cost, of course, is the number one barrier that our patients have. The accessibility, the cost, worrying about side effects, hypoglycemia is the number one feared side effect of medication, particularly insulin. But that would carry over because GLPs are typically injections, all, of course, except semioral. But treatment complexity is surprisingly overwhelming to a lot of people. So a simple once-a-week injection may actually make this seem much more doable to people. Fear of self-injection has become less of an issue over time, in my observation. But the knowledge that people need to modify their treatment over time is another issue that I think we don't always do a good job helping our patients understand. If you make these changes over time, your internal insulin-producing ability reduces, drops, those beta cells fail over time, and so you may need insulin somewhere. A GLP may be able to delay that for a period of time. And we talked about trust, and we talked about social determinants of health. So those things all begin to be barriers when we're talking about success. Now this slide is very specific in giving us some details to help break down barriers. We want to empower our patients. And if we look on the left-hand part of this slide, here are some suggestions to be sure that your patient knows that you're their champion. Diabetes-only visits, track the goals, talk about the goals, integrate the screening for the social and emotional barriers, identify patient support. I like to invite people to bring a care partner with them, prescribe thoughtfully, and of course engage the patient. And as we've said earlier in this presentation, refer to diabetes self-management education and support. And that's not just when people are diagnosed. That can be annually. In the middle section, we want to optimize care and treatment and make sure that we have done everything in our control to optimize therapy and support. So that might include things like practice-based screening for inertia, personalized care plans, and a team-based approach to increase the frequency and quality of engagement. Use A1C and glucose data to drive rapid cycle treatment intensification. I like to give my patients the treatment algorithm. The medications in this category, the GLPs, start with a very low dose to be sure people can tolerate them. But they need to be able to be empowered to increase that dose to therapeutic doses. And people can do that. If they're having trouble, they need to know that they can also contact you to extend or slow down that titration process. So helping people become empowered to do some of their own adjustments, not delay for years and years, miss an appointment, delay more months. And so those kinds of things may really help move the process along. And then finally on the right, leverage tools and technology for enhanced decision support. Follow a diabetes treatment algorithm. Standards of care are very, very current with research. We do not see the standards now have a five-year delay. They're almost outdated. We see they're current. ADA changes them when big current research studies come out that have an impact on the standards of care. So if we can follow that, if we can share that with our patients, that helps us have someone who's very vested in this whole process also helping move the process along. Patient registry helps identify this as a very powerful system tool to identify your providers list, your panel, and then integrate the decision support into the workflow. But utilize the technology to enhance communication with people with diabetes is now very common because people communicate via the portal. And if people know they can get a hold of you via the portal and you'll respond in a timely way, they have one more technology piece that lets them help move the process forward. Now, this last bullet on the right-hand side, disseminate unblinded quality metrics, is a surprisingly very powerful tool for providers in your practice because you're essentially being compared to each other, and it really kind of shines a light on some areas that may need a little more attention. So we talked about access as a big issue, and so looking at the formulary before you actually send that electronic prescription is really important. So you want to search the coverage, and formulary search, fingertip formulary, our EPIC has some formulary information embedded, but you need to understand the restrictions. PA, of course, is prior op, ST is step therapy, and so there may be some things that are required even though the GLP you choose is covered. And then we may have to identify alternatives, or you may have to look at another GLP that would not necessarily change the class of drugs, but would likely be covered better by your formulary. So looking at clinic workflow and patient management, those professional relationships with our colleagues is very important. We may be able to share cell phones and have what I call a curbside console sometimes, and that really sort of fast-forwards treatment and may help reduce clinical inertia. Having one person in your office or on your team that can do the prior ops is amazing, and everyone in the office thinks that person is going to go straight to heaven for all of that important work that they're doing, and they get very good at it. And that person then begins to know the wording to use, the important things that they have to be sure that they include when they're doing that prior op. EMR sticky notes, as message reminders, for instance, it was a nice study done out of Duke recently that showed electronic sticky notes or messages in the patient chart increased the referrals to diabetes education almost 100%. We want to be sure that patients are getting their issues addressed, that we start with that, we know where their issues are, and then we can move on to our own agenda. I mentioned earlier sharing the standards of care with your patients. We have what we call a to-do list, and it is taken from the standards of care, formatted in very friendly patient kind of format, ABC, A1C, and the goal, how often it should be done. Blood pressure, the goal, how often it should be done. And so the standards of care for that patient to have in hand help us keep our feet to the fire because the patients want to have good control. They don't want long-term complications. People want to be healthy. We want to see people as often as possible, whether it's in person or virtually, and this is very difficult to do, but probably most critical when people are first diagnosed and or if they're not at the glycemic goals they need to be and we're trying to change therapy or intensify therapy, that titration process has lots of challenges. I'm surprised at the gratitude I hear in people's voices when I call just a quick, you know, two-minute phone call the day after they may have started an injectable. See how they're doing. Did they have any questions or any side effects? Okay, great. Well, I'll see you at your follow-up appointment or I'll touch base with you on your telehealth visit. And that follow-up appointment, of course, needs to be scheduled before they leave the current appointment. Now the cost barrier, again, we've addressed that a little bit, but the problem certainly is that cost has long been the biggest barrier to medication adherence. And in fact, in 2022, over 20% of survey respondents reported that was the primary reason that they weren't being adherent to medications. So again, looking at a formulary lookup tool, coverage search happens to be my favorite. Fingertip formulary is also very popular. And again, your EMR, our EPIC has formulary information. Coverage search, in my experience, seems to be most accurate and most frequently updated. And that requires that you put in the drug, the state, and the kind of insurance, commercial, Medicare, Medicaid. And that kind of information then is color-coded. And so if I just had a patient from California call a little bit ago, and they're seeing a new doctor in California and wanted to be sure that they had information about how to get the medication. I said, well, first of all, we need to make sure it's on the formulary. So I walked through that process with them, looked it up for them, and it's color-coded. So they happen to have United, and United, of course, has a lot of carve-outs. And on coverage search, you touch United, and all the carve-outs come out. But it's green, it's covered, it's preferred. And it may say P-A-S-T, well, that's prior auth required, and step therapy. So before you ever send the prescription, you know it's preferred, you know it's tier two, and you know you're going to need to do a prior auth. So that gives you a lot of information. Patients need to, of course, know the mechanism of action and the benefits. With the direct-to-consumer advertising, people do know a lot about GLPs because they see it on TV. What I find myself doing is saying, now, let's be realistic. Your sister-in-law may have lost 80 pounds, but the data shows 13, 15, maybe even 25 pounds with the GLP-GIPs. So that's probably more logically what you could expect. People that, of course, put in their own elbow grease may lose more weight. But I think the side effects, the mechanism, those are very important. Mitigating side effects with the GI class is, I think, now much more scientifically based. When these came out 20 years ago, I told people, eat slowly, and when you're full, stop eating. Well, people with type 2 diabetes aren't used to feeling full. The neuroendocrine deficit is they don't feel full, and these drugs work in the area post-treatment to help them feel full. They aren't used to that. So they're four or five bites past it before they realize, oh, I'm full. Well, then they're in trouble with GI problems. So now that I've learned the PKPD on the GLPs, I can say to people, those first two or three days after your injection is when you're most at risk of some GI problems. So put your normal amount of food on two plates. Eat one plate. Stop eating. Give yourself some time. If you're still hungry, go ahead and eat a little bit more. So some of those more specific, more actionable coaching tips help mitigate some of the GI issues. And then, of course, if they're still having that, Zofran is very beneficial, or home remedies, peppermint or ginger, ginger ale. Some of those things may also work as well. All right. So our key takeaways today is that we want to, of course, know and share with our colleagues how the GLPs are highly efficacious in not just glycemic control, but in helping patients get to their target. The GLPs improve diabetes control, weight management, cardiovascular. They also may reduce the risk for renal issues. And now we're seeing data come out with other things that are beginning to be evaluated even more, sleep apnea, mind chatter around thinking about food all the time. So there are many, many benefits. They're underutilized, though. And if we can help our colleagues be more comfortable with prescribing these, that will be a benefit to our patients. Side effects are manageable, and we typically can help coach people around that. We can help coach when they start and when they increase and titrate the doses to be the higher risk times. But your best friend should be your diabetes educator, diabetes care and education specialist who can provide diabetes self-management education. And this slide that we end with shows you, again, some resources to help track those people down. So I would encourage you, if you don't already have a colleague that you know and love, that you look on some of these websites. And the final website here is the Consumer Guide, which is something that ADA does every year and is a very powerful patient support piece. So I want to thank you for joining us today.

patient-centered care

trust in healthcare

social determinants

diabetes management

cost barriers

GLP-1 receptor agonists

patient-centered communication

social determinants of health

patient engagement

healthcare provider trust

technology in healthcare