Meeting People Where They Are: Improving Diabetes Care and Outcomes Through Education and Collaboration Free

My personal interest in and path to working in diabetes care and education began when I was in pharmacy school at Washington State University (WSU), where I currently serve on faculty. At WSU, opportunities for pharmacists to make a difference in the lives of people living with diabetes were frequently emphasized within our curriculum by several faculty who worked as diabetes care and education specialists (DCESs) and were active volunteers for organizations such as the ADA and the American Association of Diabetes Educators (now known as the Association of Diabetes Care & Education Specialists [ADCES]), including the late professor R. Keith Campbell, Dr. John R. White, Jr., and Dr. Steve Setter. These three mentors instilled in me an early passion for person-centered diabetes care and the importance of teaching and mentoring the next generation of health care clinicians.

In addition to the teachings of Professor Campbell and Drs. Setter and White, I had another incredible learning experience while on a hospital rotation in my final year of pharmacy school. I expressed my interest in diabetes at the beginning of my clinical rotation, and my preceptor asked if I would have any interest in spending time with an endocrinologist. I jumped at the opportunity and was quickly introduced to Dr. Ken Cathcart. Incredibly, Dr. Cathcart spent 2 hours per week with me one on one, discussing diabetes-related topics. Over the course of my rotation, we reviewed, discussed, and applied the ADA’s 2004 Standards of Medical Care in Diabetes. Through Dr. Cathcart’s incredible generosity and passion for teaching, I was provided with an amazing learning experience. Little did I know at the time that he would become my endocrinologist just a short time later.

Approximately 6 months after I graduated pharmacy school, my family and friends noticed I was drinking a lot of fluids and waking up multiple times throughout the night to use the bathroom. I explained it away initially, but after a few weeks, I began feeling noticeably fatigued and experiencing blurred vision and dizziness. During a visit home for the Thanksgiving holiday, my wife, Angie, asked me to check my blood glucose. Despite my clear symptoms of hyperglycemia, I was still a bit in denial and was shocked to see my glucose reading was >400 mg/dL. We quickly loaded into the car and drove to an urgent care clinic in the area that accepted my insurance.

My urgent care visit was a bit of a blur, as I was very overwhelmed with what was happening. I told the individual that roomed me that I thought I had diabetes. My blood glucose was confirmed in the clinic as >400 mg/dL, and I was promptly administered an injection of 10 units of regular insulin. After sitting in the exam room for about 10 minutes, an individual returned to the room and checked my blood glucose for a second time. Not surprisingly, given the onset of action of regular insulin, my glucose level was still >400 mg/dL. I vividly remember sitting in a chair in disbelief with my head in my hands when I felt a poke in the back of my other arm, as I was administered another 10 units of insulin. I received a prescription for a glucose meter and metformin and was encouraged to go to the emergency department if I had any problems before I was able to follow up with my primary care physician.

I wouldn’t enjoy the best night’s sleep that evening. I woke up at some point in the early-morning hours with my heart beating out of my chest and sweating profusely. I checked my blood glucose with my new glucose meter and found that my blood glucose level was now in the 30–40 mg/dL range. What happened next was a bit of a blur. I ate the better half of a pumpkin pie and other foods prepared for our Thanksgiving gathering. The next morning, I found my blood glucose level was back to >400 mg/dL.

Fortunately, I was quickly referred to Dr. Cathcart, formally diagnosed with type 1 diabetes, and converted to an appropriate insulin regimen. But, what was striking to me through this experience was how overwhelmed I was with the diagnosis and the prospect of managing an intensive insulin regimen, despite my pharmacy training. I found myself reflecting on all the people with whom I had interacted at the pharmacy. Had I done enough to educate these individuals, most, if not all, of whom didn’t have the same background knowledge I had when diagnosed with diabetes? I quickly reached out to Professor Campbell and Drs. Setter and White for advice. Shortly thereafter, I transitioned into a clinical pharmacy residency under the supervision of Dr. Setter, during which I worked with older adults with diabetes in the home health setting. From the day I started my residency, I was fortunate to have incredible mentors encouraging me to log my practice hours and become a certified diabetes educator (now known as a certified diabetes care and education specialist), always stressing the incredible need for DSMES in the home health setting and beyond.

So many years after I first earned that certification, a huge unmet need still exists for provision of individualized DSMES for the >38 million people living with diabetes in the United States (1). Despite the clear benefits of DSMES on diabetes outcomes (2), it is estimated that only about 5% of Medicare beneficiaries take advantage of DSMES services (3). There is also a clear educational need for the nearly 98 million adults living with prediabetes (1). Fortunately, the ADA is actively engaged in multiple crucial initiatives to address the educational needs of both members of the multidisciplinary diabetes care team and people living with or at risk for developing diabetes.

Through the guidance and support of my mentors and the ADA, I have been fortunate to engage in diverse opportunities to identify and address the unmet care and educational needs of people living with diabetes, including by providing direct diabetes education, contributing to service opportunities with the ADA, and participating in multidisciplinary research initiatives.

My work as a consultant and research pharmacist in the home setting has been extremely rewarding, as working with people with diabetes in their home environment is truly meeting them where they are. Engaging with and educating people in their home provides incredible insights into core ADCES7 self-care behaviors to inform person-centered care (4). When delivering services in homes, you can observe firsthand individuals’ living conditions and any potential barriers to self-care. Often, you can gain a deeper understanding of lifestyle considerations, such as the foods available to them and their opportunities for or barriers to physical activity. As a pharmacist, I can see exactly where they keep and how they manage their medications and assess—with their permission—their use of a blood glucose meter or continuous glucose monitoring system and how they interpret and act upon their results.

One population I have found to be particularly rewarding to work with in the home setting are people with diabetes and chronic kidney disease (CKD). With approximately one in three adults with diabetes also having CKD (5), this is a large population of people who are at risk not only for kidney disease progression, but also for cardiovascular morbidity and mortality (6).

Promoting optimization of guideline-directed medical therapies in the setting of diabetes and CKD is a timely topic, particularly when considering the recent expansion of therapies to improve outcomes in this high-risk population (7,8). However, there are a variety of barriers to optimized management of CKD in diabetes (9). These barriers include, but are not limited to, gaps in CKD screening, identification, and awareness and underuse of recommended evidence-based therapies. Figure 1 highlights key strategies to promote improved management of CKD in diabetes, including efforts to increase CKD awareness and deliver person-centered education and support for both CKD and diabetes self-management (10).

Through a collaboration between WSU and Providence Medical Research Center, we conducted the CKD-Medication Intervention Trial (CKD-MIT), a home-based intervention trial for people living with diabetes and CKD (11). CKD-MIT was a randomized trial testing the impact of an in-home, pharmacist-led medication therapy management intervention on risk for rehospitalization in people with CKD transitioning from hospital to home. The intervention, which consisted of a single pharmacist home visit, was not found to reduce the risk for rehospitalization (12). We believe that a single visit was not sufficient to adequately affect the rate of rehospitalization in this sick and clinically complex population. Nonetheless, we did find that individuals in the intervention group (n = 72) commonly presented with medication therapy problems (MTPs), with 92% of participants visited having at least one MTP (12). Identified MTPs varied widely in terms of severity and type, but discrepancies between hospital discharge medication orders and what these individuals were actually taking in the home were very common. In addition, participants often presented with knowledge deficits about CKD and their prescribed medications, highlighting the immense need for individualized education in the community.

One proposed strategy to overcome barriers to optimized management of CKD in diabetes is the harmonization of clinical practice guidelines such that recommendations are as clear as possible for clinicians at the point of care. A professional highlight for me has been the opportunity to be a member of the ADA’s Professional Practice Committee, which is charged with updating the Standards of Care in Diabetes each year, including serving as the committee’s chair in 2018 and 2019. When I initially joined the committee, the ADA’s algorithm for the use of glucose-lowering therapies in type 2 diabetes was still very glucose-centric, with metformin recommended as first-line treatment, and the addition of other glucose-lowering agents largely driven by the need for further A1C reduction. Fast forward to the 2024 Standards of Care (13), the recommended approach for intensification of glucose-lowering therapies is much more nuanced. Consideration of key cardiovascular and kidney comorbidities now largely drives the selection of pharmacotherapeutic agents, with recommendations for the use of agents demonstrating heart and kidney protection for people with such coexisting conditions independent of their current A1C or need for glucose-lowering. These changes have been driven by the explosion in knowledge gained from large cardiovascular, kidney, and heart failure outcome trials, which have fueled rapid and continual evolution of guidelines from the ADA and other organizations (13–15).

In an effort to align clinical practice recommendations, the ADA and Kidney Disease: Improving Global Outcomes (KDIGO) convened a multidisciplinary group, for which I had the pleasure of serving as an ADA representative, to develop consensus on the standard of care management for people with CKD and diabetes. This joint effort resulted in the collaborative dissemination of a unified consensus algorithm (Figure 2) (10). The ADA continues to collaborate with other major sister organizations to align recommendations and messaging to the diabetes care community.

As previously noted, another major gap in the management of people with diabetes and CKD is underutilization of guideline-directed medical therapies (GDMTs). I am fortunate to work with a talented group of investigators on the Center for Kidney Disease Research, Education and Hope (CURE-CKD). CURE-CKD is an electronic health registry incorporating data from health records in two large health systems (16). A recent CURE-CKD analysis found that, in the period spanning from 2019 to 2020, only 6% of people with type 2 diabetes and CKD within the registry were receiving standard of care treatment with a sodium–glucose cotransporter 2 (SGLT2) inhibitor (17). SGLT2 inhibitor use further fell to 5% when looking at persistent use, defined as continued use for ≥90 days. These findings are consistent with other reports in the literature documenting suboptimal use of GDMTs in CKD (18,19).

Implementation and expansion of multidisciplinary models of CKD care represent a promising strategy to address underutilization of recommended therapies in diabetes and CKD. Wider incorporation of pharmacists in diabetes and CKD care teams represents one viable approach to address current gaps in treatment. Table 1 highlights key barriers and care gaps in people living with type 2 diabetes and CKD and opportunities for clinical pharmacists to address these gaps and improve care (20). Opportunities highlighted include performing medication reviews and optimization of drug therapy, assisting with access and cost barriers, coordinating care within the multidisciplinary care team, and facilitating appropriate follow-up (20). Leveraging clinical pharmacists as members of multidisciplinary diabetes and CKD care teams to optimize care and outcomes is an active area of interest for members of the CURE-CKD team and beyond.

The ADA continues to lead in addressing many of the barriers to optimal care of diabetes and common comorbidities. The ADA’s recently launched Institute of Learning is an incredible resource with easily accessible online learning options for busy professionals (21). The ADA is also hard at work to engage primary care clinicians with the establishment of the ADA’s Primary Care Council, which includes voices from a variety of partner organizations representing a range of primary care disciplines (22). Through these and other current and planned initiatives, the ADA is working tirelessly to improve the lives of all people living with and affected by diabetes.

I would like to thank the ADA again for this amazing recognition. I would also like to express my heartfelt thanks to Drs. John White, Kathy Tuttle, and Guillermo Umpierrez for nominating me for this prestigious award. I am truly honored they would take the time and consider me worthy of it. My additional thanks go to the CURE-CKD investigator team, my colleagues at the WSU College of Pharmacy and Pharmaceutical Sciences, and, finally, all of my amazing colleagues and collaborators for your continued partnership and friendship.

As previously mentioned, Professor R. Keith Campbell had a huge impact on my career and was an amazing mentor and friend. Keith was known within the WSU College of Pharmacy and Pharmaceutical Sciences for saying, “Now, go make me proud.” I am confident that Keith, himself the ADA’s 1989 Outstanding Educator in Diabetes Award recipient, would be proud to see me follow in his footsteps.

Last, but not least, I want to thank my endlessly supportive family: my wife Angie and our three amazing children Haley, Heidi, and John. I also thank my extended family who have supported me every step of the way personally and professionally. Finally, I want to thank and acknowledge my most important mentors: my mom and dad, Todd and Darla Neumiller.

No potential conflicts of interest relevant to this article were reported.