Video Practical Aspects of Establishing and Deploying CGM at the Front Lines of Care for T2D Barriers, Solutions, and Patient Identification Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Practical Aspects of Establishing and Deploying CGM at the Front Lines of Care for T2D Barriers, Solutions, and Patient Identification Overview Continue To Test Back to Symposium thank you so much for joining us today. From clinical trials to the front lines of diabetes care, I'm going to review the practical aspects of establishing and deploying. See GM at the front lines of care for persons with type two diabetes. We will review barriers, solutions and patient identification. I'm dr Eden miller, the founder of diabetes and Obesity care. I'm affiliated with ST Charles hospital in bend Oregon. I want to dive right in to discuss what a person utilizing C. G. M. And a clinician can get with incorporating that real time glucose monitoring in practice. You know, we saw right off when we added this new tool to persons who struggle with diabetes that it brings them out of the past into the present glycerine miA and helps the person anticipate the future. It is very much individually driven which really increases personal engagement rather than increasing the burden of diabetes. It's illuminating for that person to see those trend arrows. Whether there trending up or staying stable or trending down, it allows them to view the current rate of change to be able to intervene and prevent both hypoglycemia for safety as well as hyperglycemia. I think I've been most amazed and encouraged by how persons who utilize C. G. M. In that real time can see firsthand the effects that food have on their glycerine mia. Not just a general recommendations of eat better but how the individual responds to particular foods. In addition we see the time of day glycemic changes. We all have known that in clinical practice but the person may not really understand how the time of day or their activity level, both physical activity and sedentary as well as illnesses can affect our glucose. We often can illuminate stress that would have been otherwise hidden to the individual. It very much empowers them and brings a sense of awareness of their own personal glycemic journey. We also get a secondary benefit from those loved ones and caregivers. It's that ease of mind that they can track them and be notified in a real time fashion. Now we have different benefits on the clinician side. We all want our patients to increase their engagement. This really empowers them to do that. I think some of my colleagues will think that revealing the glitchy mia to the person just creates more glycemic burden but it doesn't oftentimes persons with diabetes don't know how to engage with their disease. They don't know how to make this meaning. And so even if you as a clinician never yourself engaged with the data, the person is going to get quite a bit of information to help them manage their disease but we also want them to be safe and I want to make sure you understand that C. G. M. Is not just to prevent hypoglycemia. It's not just a new way to finger stick but it does provide hypoglycemic awareness and prevention by noticing that glucose rate of change. Then the most important piece for us as clinicians is that therapeutic impact that overcoming therapeutic inertia that the reports that that data can give us and show how we have the opportunity to intervene through changing or augmenting addition even subtraction of that glucose management that we're prescribing for the person to help really overcome that pervasive barrier that we call therapeutic inertia. That compiled principal data beyond hypoglycemic risk shows glycemic variability. Which really is those highs to lows that contribute to the risk of hypoglycemia. We want to minimize that. We want to narrow their peaks and valleys. We want to be able to visualize in the office with them through this compiled gpr ambulatory glucose profile so we can have that shared decision making to really move the therapy in a direction that's individualized for the patient to get them to target. So who on a specific level could benefit from continuous glucose monitoring in the US. It is approved for those individuals with any kind of diabetes two years of age and above or pretty much anybody who wants more engagement and data as well as realization of their own glycemic journey. It's this clinicians opinion that every person on some level with diabetes can benefit from C. G. M. So you need to open your mind to its benefit to all the different components and data and relevance. It means for the person who utilizes it outside of the U. S. We are able to use C. G. M. With those who are pregnant with type two diabetes currently in the US We do not have approval for that. However, for those who have Type one diabetes in pregnancy, we are able to utilize that to help with their outcomes. I would also encourage you to those who may be present with hypoglycemia. Especially those who have been admitted have any kind of co morbidity with that. There are hundreds of thousands of admissions for hypoglycemia for our persons with type two diabetes. We especially see those who are on symphony areas and basil insulin. Don't think that those agents don't have a high offending rate of hypoglycemia. All persons on mealtime insulin or every person on a pump should be given or provided a C. G. M. For that engagement. That safety and the utility of how they're having to dose pretty frequently. If you encounter those with advanced age or complex patients who have multiple comorbidities, you know, as kidney disease and heart failure and cardiovascular disease. We really want to avoid hypoglycemia in this group there at a higher risk for that. And so that is a specific reason to site for them to be able to obtain this level or anybody in particular care situation who is not able to notify a person regarding blood sugars. This is a way for us to monitor them through a secondary person. But really it's persons who want to manage their diabetes better they want or need better engagement. They have poor glycemic profile and they can benefit from the understanding of their personal dietary activities of daily life and medic medication engagement and adherence to impact glycemic management. So pretty much after reviewing who would benefit from C. G. M. You can see that it really is designed for all persons and all persons can get something out of using this technology. Now let's review some of the 2022 previous scientific session abstracts I'd like to highlight today the impact of deploying C. G. M. On intensification of treatment for persons with type two diabetes. It's really the use of freestyle libre and how it can help overcome therapeutic inertia when it comes to intensification of treatment. You know I work with the ada on other levels. And one of the objectives that has been set aside is that therapeutic inertia is the greatest barrier in our current situation for diabetes care. And we want to leverage everything to help reveal and help move that needle to get two people to their targets. And so this was a very, very good poster, a very good study that was presented on how utilizing freestyle libra can actually help overcome inertia. It is that major contributor to those not achieving glycemic control. It's really that what we call intensification or the intensification of therapy. So this study was used to assess patients with Type two diabetes. The impact of using freestyle libre system versus blood glucose monitoring on treatment intensification. The message was looking at a match retrospective cohort study using secondary private payer claims data, including greater than 30 million diabetes drug and device claims over 850,000 patients with type two diabetes greater than 18 in Canada over about a two year period. So each month the patients were classified by level of therapy progression. Either they're on no diabetes related therapy, one agent, dual agents, triple four or more injectable GLP ones as well as basil, insulin and multiple daily injections. They were able to compile 300 about 273,000 individuals who met that criteria across all of those coast cohorts. The freestyle libre treatment group was found to have a statistically higher probability of treatment intensification relative to blood glucose monitoring. And so here we see the actual data on the left hand side, those naive to diabetes therapy and that percentage and those on existing diabetes therapy. We see the treatment cohorts whether they were using freestyle libra versus blood glucose monitoring. We see the interval for statistical significance and we see the relative risk over time of 24 months for treatment intensification. This is a big deal. It's one of the things that we see both clinically and in the data out there that we initiated therapy and we failed to do anything different with it for often several months. But by illuminating the glycerine mia, both to the provider and the person with diabetes. We get an earlier intensification or modification of treatment and thereby overcoming inertia. In other words we speed up that interventional arm and it is often through a shared type of data and this is what's great. Anything we can do to help engage the patient and their treatment help reveal to the provider of the direction that they need to go. So in addition, a few years ago, uh myself and my cohorts presented a similar poster at the A. D. A. In 2020 but this particular one was to look at the reduction of A one C. After initiating freestyle libre and persons with type two diabetes, whether they were on basil, insulin or no insulin therapy at all, they could be un injectable GLP ones but they were non insulin groups and only basil insulin cohorts and we wanted to look at the change of A one C from baseline to six months, baseline to 12 months. Win freestyle libre was added in those two particular cohorts with type two diabetes. They looked at data from three different sets linked together with the timeframe. We looked at the library view which was all the compiled data went back through quest diagnostics to look at the A. One C. And we also reconciled medications through the decision resource group. Now the baseline, A one C had to be greater than 6.5 prior to six months. And then we looked at the closest to six month and closest to 12 months a one C Data and what we saw was quite illuminating. If we look at the overall compiled data, the two cohorts remember the basil and the non insulin groups, we saw that at six months there was a 60.8% a onesie reduction in the whole compiled group that continued on to a 0.6% reduction at 12 months. Now, what was really illuminating to us is that if we tear it out the group to the right, the greatest reduction in A one C. Was in the type two diabetes non insulin group, the ones not on basil, insulin, just oral or non insulin agents. That at six months they had a 60.9% a one C reduction. We have traditionally felt like those individuals really didn't have that ability to intervene with their disease. But this study has shown us That it can and this is persistent up to the 12 months in that non insulin group 2.7. So you can see this utility in your clinical practice but there are barriers and one of those barriers that we have as clinicians is we must pause and create a workflow that works for you and your staff to identify, initiate, apply, get the data and as well as bill for the services that you're providing. And you may have to be very particular about this taking a after a lunchtime or or a time, you know, during a meeting to set aside an hour or two to identify how to create this plan. And this is one of the things that you can do from the very front of the office to the very back at our clinic as well as the american diabetes association and overcoming therapeutic inertia. One of the things that we contributed to this particular initiative is that we suggested diabetes only appointments. I know many of you are saying well I have to do other things but remember this is a chronic disease that's going to be there year after year after year. And we have to prioritize it at certain intervals. And so in my template in my office ChR system I have diabetes only appointments so that individual knows that they need to be prepared both with their technology their records as well as their mindset to really review their diabetes and as a result of that we do reminder calls to bring the diabetes related technology. Remember your diabetes only appointment is tomorrow bring your C. G. M. Or connected devices or any information you think you'll need to the appointment at our check in process we begin the downloading of the technology. Now you might do it there at the very front of your own office or it might be the start where they receive the technology they acknowledge they have technology and our back office staff begins the process. We want to make sure that the app or the computer data platforms are available whether they're on the front. I'm not telling you how to do your work flow, you know how to do it better than me. In some cases we actually download it at the very front. If some of our mazar busy, if our Emma is ready to receive that individual, they may actually hand it off to them for allowing them to download that information. Now there's another piece that is imperative. The person in your office diabetes champion or someone available at the front needs to be able to help persons with diabetes navigate the phone based applications or platforms. They're not that challenging but you have to have a working knowledge of it, of how to download it, how to have that, how to troubleshoot it, who to call and again make sure we delegate those necessary tasks of those individuals. We all share the workload, we're all on the team. But at the end of the day it just needs to get done and all persons in the chain need to be familiar with that process. Now my medical assistant or my back office staff has very clear expectations. She has a working familiarity with the CGM systems. She knows the components in other words, the sensors what they look like. They are not too many. You can know which ones they are, she knows how to set them up how to initiate them or start them. She knows how to instruct the patient, how to download that particular app on their phone, how to give them troubleshooting information through handouts or places to get assistance for what to do when it falls off, what to do. If the data isn't correct, how to best utilize it for its longest wear time. Then my medical assistant or front office staff download the A. G. P. Whether it's actually physically plugging it in through a reader for certain individuals or whether it's through the cloud based system, those desktop applications that need to be put on a computer. Now one barrier you may have is where your clinical setting is such a unique permission from administration to do these these desktop settings you either need to do that or have a separate standalone that could somehow transfer data through pdf file sharing. It's not challenging. You just need to pause and figure out what works for you. You need to have a login, profile user name and password. In fact my staff has all those usual name and passwords and I don't even know if I know the actual log in password because they have taken charge of this. The steps for downloading need to be mastered and uploading it to the chart at the appointment. Either virtually or in person. In addition it could also be separate whether you're going to review it the day before for the upcoming appointment which you still can ville. One of the things that makes me so comfortable with my workflow is that my medical assistant will already have my A GPS in the chart the day prior because she sees my schedule, she knows who are on C G. M and they're already there before I ever walk into that clinic. She is my diabetes champion. The one who enjoys this who finds the ability to do that and so identify that in your office. You can see here this is the freestyle libre system. Both the application for the patient as well as the loved one and the desktop version for you to download. The freestyle libre Phone app has two separate apps the 14 day and the library to for both IOS and android. That's that forward facing patient ability to look at the data. Now if you have a person who's technologically challenged, you can always obtain a reader that isn't phone based. We also have the library link 14 day and library to for loved ones. You can see that on the right hand side. So that way they can follow along with the library system. What's most important is to make sure that your clinic has the library view for all of the freestyle libre systems doesn't matter which one it is in order to cloud based through the phone or directly plug in the reader to obtain that data. Now if we switch to the decks. Com we have it's phone applications on the left as well as what we call those pastors right the watches the different applications to view data. And then we also have the share for those who want to follow along as well in the family and clarity is the downloadable report platform that needs to be on your desktop and your clinical practice. That allows you to both also put a plug in the direct reader that is also available for dex calm or obtain the data through the cloud. Medtronic predominantly uses the phone based system for their guardian and you have connect for loved ones to be able to follow on. And it's the care link software that we're able to upload those reports through the cloud to be able to get their data. Now there are basics for building of C. G. M. You really have to ask yourself these two questions. Number one who owns the equipment. Is it the person with diabetes or the provider? Because there are different codes for each of that. We want to make sure that we're going to be using it greater than a day but there really is a minimum of 72 hours of where I know you might say well why do we say that? Well the data doesn't become meaningful at all until we get at least 72 hours. Now as I mentioned earlier you can download the reader which is the direct ability to look at those C. G. M. Data or cloud based through virtual. So if you had a person with a reader you couldn't see them necessarily virtually. Unless they themselves plugged in their device through an application at home that you could share the data. But if you do have the the phone based system that can be obtained at any time electronically and you can view that data pretty much in a real time fashion. Now you can charge the day of the building of the mm code whether it's virtually or in person or any time you analyze the data. If you do it separately you can build that separate cpt code for that analysis or you could pair it with an E mm visit, As I mentioned the interpretation of the data for full meaning is 72 hours of where but again face to face is not required. Now there are limitations who can build, it's pretty much those who can prescribe any physician nurse practitioner or P. A. Are able to build these interpretation and applications for C. G. M. So here are the three codes and you can see what I mentioned just previously. So these three cpt codes are all you're going to ever need and you're going to use one of them more than the other. But to bring a little bit of clarification the 95249 is a personal see Gm Again patient owned patient viewed. They receive that C. G. M. Where you're going to apply it started up orient them put the amount of the technology, Make sure that they have an up and running C. G. M. That is at 95249. You can do that one time a month. Now why would I do that? Maybe you have an elderly person who's utilizing C. G. M. They're not quite comfortable with doing it. You identify them in the office, you started in the office, you download the application, you get a reader, they feel comfortable, they come back again another month because they don't quite know how to do it. You can build for that. It's your time in applying this. My M. A. S. Do this. Yes I have the ability to do it the capability but they are so good with their workflow. They do it as a part of their ongoing day. I walk out I say see GM start in room one and they have it down to a five minute kind of application. It's not that challenging. You just have to have that workflow Now. is a very specific. See GM starting code, it's for professional, it's a different reimbursement because you as a clinician own the CGM system. It's provider owned, you've paid for it, you have it, you're going to apply it. This is the easiest see GM to use because there are no barriers for getting it. You know what I mean by that coverage, Medicare and Medicaid cover it and you can do it up to one time per month for interpretation of the data changing and therapeutic decision making. However, some of these systems are blinded to the person so you miss that whole personal benefit. Some of them you just analyze the data later when they bring back the sensor or they're able to bring back their particular see Gm they're using. So there is limitations with it from the aspect of utility but the barriers are pretty much none whatsoever. Now the code you're going to use over and over again is 95251. That's that interpretation. It's your time looking at the data analyzing it, making therapeutic changes, discussing it with the patient whether you're doing it previously you tack it onto an E. M. M. Code whether it's a virtual or in person. You can see you can do this on every clinical level. You can also do that at least every one time per month. Now that code that 95251 is going to be for personal and professional C. G. M. So that's the code you're going to use over and over again. So take the time now to establish a clinic workflow to familiarize yourself with diabetes technology This time. This investment will save countless hours and maximize your patients interaction. Once you begin this it's going to have a new world opened up to you of how to engage and intervene and your patients are going to love it. Always feel free to contact me personally with any questions I'm here for you. I want to share some of my experience with you as my colleagues and be there as a resource. Thank you so much for joining us. Published May 27, 2022 Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
