DR. JOSEPH: Collaborative care in my practice, in our practice, here at Ohio State, is really all about team-based multidisciplinary integrated care. We know that, when we think about diabetes, that diabetes is a complex condition, and it really takes multiple strategies including medications and lifestyle modifications to appropriately manage someone. There’s a self-management to diabetes. So, because of this, a teamwork approach to diabetes care may be more effective in helping people cope with the demands of controlling diabetes. 

And so central to this, when we think about this collaborative care model, is shared goals within and across settings to provide coordinated high-quality patient-centered care. And I really emphasize the patient-centered care piece of that. And this really kind of comes from the chronic care model that we developed so long ago in other healthcare delivery models that really emphasize team-based care.

Advanced practice providers, pharmacists, registered dietitians, nurses, physical activity trainers, social workers, community health workers, podiatrists, psychologists, all of these individuals can be a part of a collaborative care model to really address diabetes management for individuals. 

And what we’ve seen from models such as this, is that they improve outcomes. When we look at hemoglobin A1C, there have been meta-analyses to show that A1C is reduced by about half a percent by models such as this. There’s also reductions in blood pressure and improvements in quality of life.

And the one question that usually comes up is, well, what is the cost of that? Is that going to cost our practice or our health system more? And now we have meta-analysis-based data to show that it doesn’t cost more, that the costs are comparable in these collaborative care models.

At OSU we continue to innovate to employ collaborative team-based care, both within our health system and, just as importantly, extending into the communities where individuals live, work, pray, and play. We have also emphasized the importance of addressing traditional components of diabetes care, including self-management and lifestyle change, along with novel components, including addressing non-medical health-related social needs like housing, like food insecurity, like transportation, because these can all be barriers in management of diabetes. And when we do this, when we model this collaborative care process, we know that we are in line with the most recent recommendations, including the National Clinical Care Commission report to Congress. That, within that report, I love this quote, it said, “Health systems must proactively deliver high quality, individualized diabetes care, and community resources must align with the self-management needs of these individuals.”

DR. JOSEPH: Next, I would like to pass it to Janet Zappe to talk about our diabetes self-management education and support program.

JANET ZAPPE: Thanks, Dr. Joseph. No one person’s journey with diabetes is the same. And therefore, we offer a wide variety of classes and individual appointments so that we can really individualize and personalize what is going on. And we ask each person when they come to us to complete a self-assessment. Sometimes they’ll say, “Well, that information’s in the chart. Why do I have to fill it out?” Because the reality is sometimes that information is not the same because diabetes is dynamic, meaning that sometimes you need to change your medication. Sometimes you are now more active than you had been before. 

And sometimes when somebody meets with a diabetes care and education specialist, they’re a little more honest. And I say that because they don’t want to disappoint their physician. And that’s why collaborative care is so important. There are different people interacting with that same person throughout the journey of their life. Just today I met with somebody who’s had type 1 diabetes for 45 years and until a couple years ago had never met with a diabetes care and education specialist. And it’s a different perspective, right? There’s more than one way to work with diabetes. And at Ohio State, we also offer classes in the evening and on the weekend. We offer it throughout the city so that we can try to meet people where they are at and when they’re available. The other thing that I will tell you that I think is really important in this collaborative care model and is a critical element of diabetes self-management is that the person themselves sets a behavioral goal: taking their medication, getting more active, checking their blood sugar.

When they set their goal, they also say, how are they going to get there? And what I do after I meet with them is I route back to the physician, “Hey, they are willing to start packing their lunch three times a week.” The goal for that is that when that referring provider sees that and they have a follow up, they could say, “I heard you were going to work on packing your lunch.” Swapping out diet soda, taking diet soda instead of sweet tea, or whatever their goal might be. Then that can layer on the reinforcement. I also make sure that I tell the referring provider that the goal has been achieved, “Hey, they are walking more.” Because people with diabetes are people, and they’ve got a lot going on in their lives, and they need that encouragement and that support. So, I’m really excited that I can work with a great team and that they can continue to support the person where they are at, and making the change that is helpful and impactful to them.

DR. JOSEPH: Now, Janet, can I ask you the question about that? So, I refer every patient to diabetes self-management education and support. My understanding though is based on some of the national guidelines, we miss a lot of people, ranging from 5–10% of people within their first year are able to get in and get diabetes self-management, education, and support. Are there any folks who we should not be referring to diabetes self-management education and support? My understanding is everybody needs to come see you, but I want to make sure that I’m thinking about that correctly.

JANET ZAPPE: There are key elements in time. Of course, newly diagnosed, change of medication, change in their personal life that is impacting their diabetes: think about a pregnancy, think about a wedding, think about the death of a longtime spouse. Those are going to be really important. And I think that people with diabetes are 9.9 times out of 10 really surprised that we’re not here to judge them, we’re here to support them and we are here to help them on the journey. And that if it was as easy as take this pill or walk two miles, we wouldn’t have a job. It’s not that easy. Life gets in the way.

DR. JOSEPH: I think we should bring on Allan Sommer to talk about all of his great work with Exercise is Medicine and all the great community work that he does. Allan, tell us a little bit about yourself and the great Exercise is Medicine Program.

ALLAN SOMMER: The Exercise is Medicine Program is a global initiative that is intended to link the clinics to the community, and really incorporate physical activity as a vital sign in the treatment and management of chronic disease. So, anyone who is not reaching the exercise recommendations of the 150 minutes per week of moderate-intensity exercise, or the clinician and providers feel that exercise could be beneficial in their plan of care for chronic disease, we have them referred into the Exercise is Medicine Program.

And this link to the clinic, for us as community programming, has a huge impact. We heard Janet mention that oftentimes in the chart, we’re going to get different answers from when we’re speaking one-on-one with an individual because they really would like to make their doctors proud or impress their provider. We see this with exercise. We all know that we should be exercising more and that’s simple, right? But when you hear that from a spouse or a loved one or a child, it does not carry nearly the weight that it does when it comes from your physician or your specialty provider, like an endocrinologist. So, when folks do get referred to the Exercise is Medicine Program, we oftentimes have them calling as they’re leaving the clinic to get enrolled in the program and get started.

Once they come into our program, again, we tailor exercise to meet them where they are in terms of their physical activity levels, their chronic disease limitations, and really provide that personalized plan for exercise. And Janet mentioned this earlier as well. One of the key components to this is the behavior change, appropriate goal setting and providing the individuals the support and the community that they need in order to be successful.

When we do get these one-off cases where someone may not be most appropriate for the program, we can communicate directly with the provider and find the licensed skilled care that may be appropriate. 

One of the things that I did learn from Dr. Joseph, being a researcher and a clinician, a lot of times we are introverted by nature. And in order to be successful, especially when it comes to collaborative care and coordination of care, it really requires us to step outside of our comfort zone, and me being forced to be an extrovert rather than an introvert. But I think that the thing that is really beneficial and the patients really seem to love about this type of model is that feedback loop to the providers. And Janet touched on that as well, really having everything on and everyone on the same page to make sure the quality of care is above and beyond what the patient’s expectations are and that leads to better outcomes.

DR JOSEPH: That’s great, Allan. And one question I’d have for you is, tell us a bit about those outcomes. You guys collect data on physical activity and blood pressure and different pieces. Tell us, are outcomes improving with the Exercise is Medicine Program? 

ALLAN SOMMER: At the end of the 12-week program, we’re seeing a greater than 60 minute per week increase in physical activities from their baseline levels. And then at the end of six months post-program completion, they’re maintaining more than 45 minutes of exercise per week at that moderate-level intensity compared to where they were when they started the program.

So, we know and the research has shown that exercise is beneficial to many risk factors associated with chronic disease. And when we think about the ABCs of diabetes—the A1C, the blood pressure and cholesterol—we know that exercise can positively impact those risk factors. So, the data that we do collect supports a lot of this research. So, in our Exercise is Medicine Program, at the end of those 12 weeks, we’re seeing decreases in systolic blood pressure of over three and a half millimeters of mercury, diastolic blood pressure reductions of almost two millimeters of mercury, significant decreases of waist circumference, body weight of two and a half pounds... 

We also collect some quality-of-life measures that can be impacted by exercise. And we see that this 12-week intervention improves depression scores in the PHQ-9, improvements in perceived stress and improvements in the mental health component of SF-36 scoring. All this to say that we are seeing significant and meaningful improvements in both our risk factors for diabetes, cardiovascular disease, as well as mental health benefits from the exercise program.

DR. JOSEPH: Well, that’s fantastic Allan. And I think, really speaks to the great work of the Exercise is Medicine Program. The other thing I know from your previous work and also conversations we’ve had is that you have locations all over Columbus, including in under-resourced areas. And I know you’ve put together funding to ensure that everyone can have access to the Exercise is Medicine Program. 

So, whether you are in a community that has lots of resources or a community, that resources may be more limited, everyone has equal access which is critically important when we think about the care of diabetes.

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JANET ZAPPE: The Diabetes Device Clinic was designed about six or seven years ago because putting somebody on an insulin pump and saying, “Okay, you’ve got it right, here’s a button to push,” wasn’t enough. And it’s pretty overwhelming. And there’s a lot of scenarios, using it with exercise, using it when you’re stressed. So, we developed that with Dr. Kathleen Dungan. And at that clinic, the person after they go on the technology, usually within 2-4 weeks, they come back to the clinic and it’s a combination appointment, so that they are seen by a diabetes care and education specialist like myself or one of my teammates. And then they immediately are seen by Dr. Dungan. 

We have so much cool technology right now. But you have to know what it means. You have to know how to read the report and how to implement that on a daily basis.

DR. JOSEPH: Can you tell us a little bit about the integrated type 1 diabetes clinic? It’s one of my favorites for my patients with diabetes. And so, I would love to hear a little bit about that.

JANET ZAPPE: Yes. Just in the past year we started a clinic on Thursdays with Dr. Wyne, who is the director of our Type 1 diabetes program and Jenna Scudder, who is one of our fantastic diabetes care and education specialists. And in that clinic, she’s working hand-in-hand with Dr. Wyne. It is a way to introduce people to a diabetes care and education specialist. It’s a way to capture them when they’re there. A lot of the people that we see at Ohio State, about 80% in the past year, are of working age, and that means they’re taking time away from work. So, in this integrated Type 1 care model, they’re going to see the doctor and a diabetes care and education specialist.

I have one other model, Dr. Joseph and Allan helped us with this, and it’s called Staying the Course. It is a class that we developed after you had the initial education. And what we’ve done is we have brought in an expert from the Ohio State community, and last month, Allan Sommer was that expert. And it’s an hour session. And Allan came in and talked about exercise, and he made our people exercise in the class, right? So, we know that we don’t know everything, we the diabetes care and education specialists, right? So, we bring in each month an expert from Ohio State, a dietitian, we actually had a yoga instructor two months ago to talk about stress, exercise. We bring in pharmacists. And that way, people are continuing their journey with their diabetes and we’re capitalizing on the great brain power and people that we have here at Ohio State to be the experts in those subjects and bring that knowledge and that hands-on learning directly to the people with diabetes.

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DR. JOSEPH: We have a program, a pharmacy-based collaboration program, where individuals with an A1C greater or equal to 9% within our accountable care organization are referred to a pharmacist. And these pharmacists meet with the individuals and coordinate their diabetes care. What’s great about this model is while some of the physicians and nurse practitioners may have more limited availability, the pharmacists have more frequent availability. So, they can meet with individuals on a more frequent basis and make those changes that we know are critical to improving diabetes control.

And so, with that model, they are able to address the care of individuals. And what we hear from our patients is that they love to meet with our pharmacists. Our pharmacists have more time with them, and they begin to develop a relationship with individuals similar to how clinicians have relationships with individuals. So that’s our pharmacy-based collaboration.

So, the second one is our Transition of Care Discharge Clinic. And that is at OSU Hospital East. That’s one of our community hospitals here at Ohio State University Wexner Medical Center. And it’s led by Dr. Kathleen Wyne. And she has a great team of individuals who work in the Transition of Care clinic.

What we had found was that individuals who were being discharged from the OSU East Hospital had a higher rate of both readmissions and emergency department visits within 30 days of discharge than some of our other hospitals within our health system. And what Dr. Wyne was able to do was to put together a clinic where individuals could come on Fridays after they were discharged and meet with individuals. And when they met with them, they reviewed all of their medications that they were on. They ensured that the medications they were prescribed, they were able to get them from the pharmacy. They were ensuring that individuals understood their treatment and care plan.

And with this wonderful innovation in care, what they saw was that individuals who were involved in this Transition of Care Discharge Clinic, they were seen—for a 30-day readmission or ED visits—about 18% of individuals who were seen at the clinic had a 30-day readmission or ED visit. But among individuals who were controls for this project, 36% of individuals had a readmission or an ED visit. So, this reflects a huge decrease in readmissions and emergency department visits. What I’m not telling you is that they also coordinate care to ensure that they get back with their provider on the outpatient side. And we’ve seen improvements there too. So, it’s really an inpatient to outpatient care model to advance the treatment and care of diabetes.

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JANET ZAPPE: The ‘U Got This!’ program is a national initiative. The diabetes community discovered just maybe a couple of years ago that African Americans, in particular, were offered the use of a continuous glucose monitor significantly less. And then if you layer on people who don’t have, who are on government insurance, even less than that. So, this great program is held in a Y. Right now, the Y that’s very close to my center where I’m working. And it is there… there are different hospital representatives from across Columbus. It’s not just Ohio State.

We’ve got community partners, we have other hospitals, but it’s really important it’s right in the heart of this community. We have community health workers there. People get a lifestyle coach. They’ve been known to come to their house to pick them up to get them over to the Y. And our commitment has been to have the diabetes care and education specialist there at the center to talk to them because it’s not... What we know is just putting a sensor on is one thing. It’s keeping it on, it’s understanding what it’s saying. It’s using that data. And so, we work together with that person to know what it means.

DR. JOSEPH: That’s fantastic, Janet. And I think, the biggest thing you said there is it’s where the person lives. It’s where they are. It’s in their community and that’s so critical to engaging with individuals around diabetes management. 

Another program we have externally is our Food Farmacy Program. And we know that one out of five individuals living with diabetes in the United States may not have enough food at home. And this has a severe impact on their blood sugar control. There are studies to show worse blood sugar control as well as worse hypoglycemia among individuals who do not have enough food in the household. And so, we have a Food Farmacy Program where individuals can get produce on a weekly basis in partnership with the Mid-Ohio Food Collective instead of the normal monthly basis. And this has been critical throughout the pandemic. But even now, coming out of the pandemic, we know that some of the benefits that individuals were eligible for to increase the amount of food they can get are starting to disappear. And so, this program is even more pivotal now to address those non-medical health-related social needs barriers to allow for successful diabetes management. 

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DR. JOSEPH: Lastly, a project that I’m very involved in is our LINK project. Earlier I kind of discussed that one in five individuals living with diabetes are also challenged by food insecurity. And what we do in the LINK project is we are engaging them with the Food Farmacy Program, which I talked about earlier. But in addition to that, we have a diabetes culinary education intervention where they get diabetes education and they get cooking education at the same time. Very, very innovative, led by Jennifer Shrodes, one of our excellent registered dietitians and certified diabetes care and education specialists, as well as two chefs here at Ohio State. But we’re also looking to say there are also other barriers out there, those non-medical health-related social needs. And so, we’ve partnered with a community organization, the Health Impact Ohio, and individuals can get those social needs addressed through a community health worker in their platform.

So, we’re trying to understand, can we give food alone? And is food alone enough to improve blood sugar control in diabetes? Or does it take food plus diabetes education and cooking education, or does it take food plus those education pieces and addressing those barriers, those social needs that individuals have to improve blood sugar control? And so, we’re really excited about that NIDDK-funded grant as well, and really trying to innovate to not think about today, but to really think about tomorrow and where we will be needed in diabetes treatment and management.

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ALLAN SOMMER: The community programming was impacted differently in the community than the clinics. The clinics were operating at normal capacity or what could be seen as normal, while the community programming was severely limited. As we know there was a major shutdown that happened across all sectors. And the fitness centers, as we know, was one of the last sectors to open.

This created many staffing problems with the delivery of the Exercise is Medicine Program that I mentioned earlier, as well as a lot of the educational opportunities that we provide to our community members. So as the staffing numbers went down, we weren’t able to deliver the same quality type of programming that we had in the past. When the community centers, the fitness centers and the gyms did open, they were under great restrictions.

So, all of this led to a great reduction in the quality and capacity of the programming that we could offer at the community centers. In addition to the restrictions that were placed on the community centers, we also know that there was increased risk of complications of COVID-19 with those individuals who had comorbidities. So, these chronic disease conditions that were being tailored by the Exercise is Medicine programs that have exercise helped treat and manage these conditions, we weren’t sure how individuals would respond to the reopening of our fitness centers and our community centers. But what we found is because of the collaborative care and these clinicians that were providing the referrals and, they knew that the programs that they were referring to, the individuals were trained in proper safety protocols and procedures, that the providers as well as the patients felt comfortable and safe knowing that we were following all of those protocols. And what we found is once we opened things back up after the pandemic participants were very motivated to come back. Again, I think it goes back to this idea of the impact that the provider has on referring someone to use exercise as a tool to help manage their diabetes.

And in the off cases where some complications arise, I think that this type of collaborative care is important. Because if someone does have some severe conditions or complications, then we have that direct line of feedback directly to those providers, whether it be their clinical specialists like Dr. Joseph and the endocrinology clinics or their general practitioners. So again, I think that it was great to see the fact that the collaborative care led to a trust in the community programming that was available, which initiated folks to get back into the fitness centers and in maintaining their activity levels.

JANET ZAPPE: You know, Dr. Joseph, another area that became really important about telemedicine was that at Ohio State, in our diabetes population, we do have a pretty high percentage of people who do use technology, continuous glucose monitors, smart pens, insulin pumps. And what we found during COVID in particular, as we switched to telemedicine, not everybody had the internet. Not everybody had the way to get that data to you. And this was especially true in socio and economic areas that just didn’t have the money to be able to pay. They didn’t have the broadband to be able to do that. And so, then people with diabetes who are at really great risk for serious and worse complications from COVID struggled to be able to get the full data to their providers. And one thing that my team did is, before a doctor’s appointment, I’d tell them… we literally would get on and they could not upload. I was on the phone with them. “Tell me what your basal rate is, tell me what your insulin is, tell me what your time and range is.” And I would document that and then route that to our doctors and our advanced practice providers, so that when they had an appointment, they had some real data, not the same as an upload electronically, but it really made sure that we did not miss people who otherwise we’d say, “I’m not sure what we can do.” We were able to get more data to them.

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ALLAN SOMMER: The patients have been very receptive to collaborative care. I’ve heard many stories from the participants at our community partner locations, from our internal sites when we’re focused on the Exercise is Medicine Program. The underlying benefit that they see to this is this direct connection to the clinic and the sharing of information in this well-rounded comprehensive care. Janet had mentioned earlier how I had helped with the diabetes educators understanding the course. I had multiple people during that session express strong desire to have all of their care coordinated within the electronic medical record. PTs talking to the dietitians about, you know, I know that I should be exercising more and that will lead me to burn more calories, but the physical therapist said that I needed to do this. Or, you know, getting that back to the endocrinologist or their primary care provider. So, this really high desire for everyone to be connected on a much more comprehensive level to keep this care coordinated and streamlined. Dr. Joseph, what is your perspective from the clinic? 

DR. JOSEPH: My perspective from the clinic is that the patients love collaborative care because it is everybody working with them to improve their lives, right? And I get nothing but positive feedback on that when someone goes to Exercise is Medicine or when someone goes to our diabetes self-management education and support programming or any of our collaborative programming, they really are truly appreciative of it. I’ve got a couple specific comments on our pharmacy-led programming recently, where they loved meeting with the pharmacist, and then they saw diabetes self-management education and support specialist after that. And they’re coming back to me and they’re telling me all these great stories from both visits, right? And so, individuals really love when we’re able to wrap our arms around them and help them on their journey with diabetes. Janet, how do you see it from your perspective? 

JANET ZAPPE: People really want to come to one center where everybody can communicate. Recently I saw a person who was going to have a gynecological procedure. And she thought... They told her she’d have to take off her insulin pump. I was able to route to both her endocrinologist and the gynecologist. “This is what she’s being told, I think this would be a better route.” And they were able to both communicate. I communicated back to her, and so she knew going into her surgery what she would be able to do about her diabetes and about the tools that she had. So, people, they love that their different providers outside of diabetes know what’s going on with them, and they don’t have to repeat exactly the same story. And they know that we’re looking out for them.

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DR. JOSEPH: I’m very proud to say that when we look at our diabetes self-management education and support program, that there are no differences in A1C reduction by race or ethnicity. And some of the rationale for why that is, is that we are able to review the data on a consistent basis. We have... As Janet mentioned earlier, we have access nights and weekends. We are around the clock here trying to ensure that we are available to individuals. And then Janet and her team have put a great focus on culturally tailoring much of the education that we provide here at OSU. 

So that’s where we are now. We are not seeing disparities within our programming as it currently exists, but we do not want to rest on our laurels. We really want to think about future innovations. And that’s where we’ve been really blessed to be supported by additional grant funding to develop the next generation of innovations. We have a family-dyad-focused diabetes self-management intervention for African American adults that’s led by Dr. Jie Hu funded by NIDDK. We have another project called Achieve, where we’re working with pregnant women with type 2 diabetes who are Medicaid enrolled. We are getting them continuous glucose monitors. We are getting them an app, and in that app, they can put in their obstetrical challenges as well as their social needs. On the other end, there is a provider dashboard and on that dashboard individuals can—from the diabetes care team, including a community health worker, a nurse, an endocrinologist, and an OB-GYN—can all review the dashboard and help to provide an enhanced care for women who are pregnant and Medicaid enrolled.

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ALLAN SOMMER: You know, we mentioned earlier about some of the barriers to some of this programming that’s there. And Dr. Joseph did mention some grant funding that allows access to everyone regardless of resources because of some grant funding that’s available. And my ultimate goal is to take the results from this out-of-pocket programming or grant-funded programming and show the benefits and sing, sing the praises of collaborative care and the outcomes that can be seen. So that way, this can become eventually a reimbursable type of expense, because we do show, and we do see, that through a collaborative care model with things like exercise, it’s oftentimes a very low cost to implement and deliver this type of programming that has substantial benefits in the long run.

Janet, I guess I’ll throw it to you to see your perspective on where things are going with the diabetes educators.

JANET ZAPPE: I think diabetes care and education specialists have long been champions of collaborative care. We realize it’s... We can’t be an island, and it’s not the best care for people with diabetes. The national standards will tell you that when you receive a referral, you need to communicate back to the referring provider. One thing that I really try to maximize is our electronic medical record. Dr. Joseph may send me the referral, but I’m also communicating back to the primary care doctor. I think it’s important that the primary care doctor know that the person came to diabetes education and what the results and what those goals were.

DR. JOSEPH: For me, I just think that we are disseminating what we’re doing. We’re talking about it around the country, in that everything we do, we evaluate it, right? It’s all on an evaluation-based model. Which, I think is incredible from a quality improvement standpoint. And so, we will continue to disseminate, we will continue to discuss these improvements in care. We will continue to discuss why it’s critical to have diabetes self-management education and support in the center of any diabetes management program. And so with that work, we will also continue to center equity and ensure that everyone has an equitable opportunity for a long life, a healthy life, living with diabetes.

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