Potential Barriers and Suggested Ideas for Changeeqipp.aap.org/File Library/Courses/Diabetes/Tools...Potential Barriers Suggested Ideas for Change ... (ISPAD) Clinical Practice Consensus

STEP Up Diabetes Care Screening, Testing, Education, and Prevention

Copyright © 2012 American Academy of Pediatrics. All rights reserved. Page 1 of 7

Potential Barriers and Suggested Ideas for Change

Key Activity: Confirm the Diagnosis of Diabetes (Primary Audience: Generalist; Secondary Audience: Subspecialist)

Rationale: The delayed recognition and treatment of diabetes can significantly affect health outcomes, including the development of life-threatening diabetic ketoacidosis (DKA) in children with new-onset of type 1 diabetes mellitus. Patients with new onset diabetes may present to their doctor with classic symptoms of diabetes (polyuria, polydipsia, polyphagia, weight loss), yet key tests are not ordered immediately, thus delaying the diagnosis and initiation of appropriate treatment. In addition, some obese patients may have asymptomatic type 2 diabetes, yet the diagnosis is delayed because appropriate screening tests are not performed in a timely manner.

Potential Barriers Suggested Ideas for Change Still Not Seeing Results?

Gap: Pediatricians are not aware of their role and responsibilities for diabetes care and/or the wide range of interventions needed to improve diabetes outcomes.

Pediatricians and/or staff members are unaware of the important role they play in diabetes care. Or, staff are unaware of recommended screening, diagnostic, and therapeutic actions to support favorable health outcomes of patients with diabetes.

• Review the guidelines that outline the screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes:

The 2012 Position Statement from the American Diabetes Association (ADA), Standards of Medical Care in Diabetes

The AAP policy, Type 2: Clinical Practice Guideline for the Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents (Check back for link; anticipated release early 2013.)

The 2011 ADA Position Statement, Diabetes Care in the School and Day Care Setting

The 2011 NHLBI guidelines, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents

The 2009 International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines

The 2005 ADA position statement, Care of Children and Adolescents with Type 1 Diabetes Mellitus

The 2003 AAP policy from the Committee on Native American Child Health and Section on Endocrinology, Prevention and Treatment of Type 2 Diabetes Mellitus in Children, With Special Emphasis on American Indian and Alaska Native Children

• Discuss the complex nature of diabetes care with staff and the importance of guideline-based care in the medical home that addresses many issues, including: Making a timely diagnosis Recognizing symptoms of diabetes and

DKA Ordering appropriate studies Recognizing and managing

hypoglycemia Documenting regular measurements of

growth and blood pressure Referring patients as appropriate to the

diabetes care team for management and education

Communicating frequently with the diabetes care team

• The ADA’s standards of diabetes care are revised annually and new evidence is incorporated.

http://care.diabetesjournals.org/content/35/Supplement_1/S11.full.pdf+html

http://care.diabetesjournals.org/content/29/suppl_1/s49.full


http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf



http://www.ispad.org/FileCenter.html?CategoryID=5

http://care.diabetesjournals.org/content/28/1/186.long


http://pediatrics.aappublications.org/content/112/4/e328.full.pdf+html






• Review the policies that outline responsibilities for coordination of care between the pediatric medical home, the diabetes care team, and other providers as an important component of high-quality care:

The 2002 AAP Medical Home Policy Statement (reaffirmed 2008)

The 2012 AAP policy statement, Patient- and Family-Centered Care and the Pediatrician's Role

The practice lacks a champion to guide and improve diabetes processes—someone who will obtain the necessary support to drive improvement and spread it throughout the practice.

• Identify a diabetes champion in your office who can serve as a resource for providers and staff members. He or she can help identify and educate others about their roles and responsibilities for diabetes diagnosis and ongoing management.

• Encourage this person to meet with others in the practice, gain their support, and/or invite them to join a quality improvement (QI) team for diabetes care.

• Offer this individual an opportunity and incentive for professional development related to diabetes (eg, time and reimbursement for participation in CME educational meetings on diabetes topics or participation in local or regional collaborative activities and/or state advisory committees).

• Review the 2012 Position Statement from the ADA, Standards of Medical Care in Diabetes, to understand the importance of placing a high priority on diabetes care for children in your practice and on the wide range of interventions needed to improve diabetes outcomes.

Gap: Appropriate tests to confirm the diagnosis of diabetes are not ordered or are not completed on a timely basis.

Physicians and/or staff are not recognizing classic symptoms of diabetes and are not ordering appropriate tests.

• Make sure staff is informed about classic symptoms of diabetes: polyuria, polydipsia, polyphagia, and weight loss.

• Train staff to take a thorough health history and consistently ask about symptoms of diabetes—especially in patients who are vomiting or ill. (See example questions to ask when considering a diagnosis of diabetes.)

• Put processes in place to ensure staff consistently and accurately records measures of height, weight, BMI, and blood pressure. Plot measurements on growth charts in order to make comparisons and to draw conclusions about what you see.

• Establish clear processes to order appropriate diagnostic studies at the time of initial presentation for patients with two or more classic

• Schedule a “brown bag” meeting with staff members to review a clinical case and educate them on symptoms and signs of diabetes, appropriate studies to order, and the critical importance of making a timely diagnosis.

http://pediatrics.aappublications.org/content/110/1/184.full.pdf+html





http://www.cdc.gov/growthcharts/cdc_charts.htm



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? symptoms of diabetes (polyuria, polydipsia, polyphagia, or weight loss). See example algorithm for diagnosis of type 1 diabetes, which delineates actions taken and tests ordered based on severity of symptoms. Studies include: Urine and/or serum glucose test Serum glucose test if urine glucose is positive Serum electrolytes (including CO2) and urine ketone tests if serum

glucose is less than or equal to 200mg/dL • Ensure that urine and blood testing materials are readily available.

• Put checks and balances in place to ensure the above are tracked through completion in a timely manner.

Physicians and/or staff do not proactively order appropriate tests for asymptomatic patients who initially present with risk factors of diabetes.

• Train staff to identify risk factors of diabetes in patients, as noted in Table 5 of the 2012 ADA Position Statement.

• Train staff to take a thorough health history and consistently ask about polyuria, polydipsia, polyphagia, and weight loss. Ask about these symptoms, especially in patients who are vomiting or ill. (See list of example questions to ask to help identify symptoms of diabetes.)

• Put processes in place to ensure staff consistently and accurately record measures of height, weight, BMI, and blood pressure. Plot growth measurements on growth charts in order to make comparisons and to draw conclusions about what you see.

• Establish clear processes to order appropriate diagnostic studies within 3 months of initial presentation for BMI ≥85th percentile for age and gender, weight for height ≥85th percentile, or weight >120% of ideal for height plus two or more risk factors of diabetes. See Table 5 of the 2012 ADA Position Statement.

Studies include: fasting glucose, A1C, or 2-hour glucose tolerance test for patients ≥10 years old. Ensure that testing materials are readily available or that a laboratory referral path is organized.

• Schedule a brown-bag meeting with staff members to review a clinical case and educate them on symptoms and signs of diabetes, appropriate studies to order, and the critical importance of making a timely diagnosis.

Diagnostic tests are ordered, but are not documented and/or results are not tracked through to completion.

• Establish clear roles and responsibilities for obtaining and documenting all diabetes symptoms, risk factors, and screening services and their results for these actions. Train staff to check for circumstances where diabetes screening results may have been missed or not documented.

• Discuss the importance of adequate documentation with staff to accurately and completely reflect the care provided to the patient. Quality documentation is important

http://www.cdc.gov/growthcharts/cdc_charts.htm




• Recognize that without adequate documentation important family discussions may not take place and treatment may not be initiated:

If test results are normal, provide parents/guardians with needed reassurance. Inform parents/guardians that screening does not absolutely rule out the future presence of diabetes. Let them know that surveillance for future risk of diabetes will be repeated as clinically indicated.

If test results confirm the diagnosis of diabetes:

− Consult with parents/guardians about next steps.

− Provide diabetes information and linkages to community and family resources/support such as those available from the National Diabetes Education Program (NDEP), Juvenile Diabetes Research Foundation (JDRF) and the American Diabetes Association (ADA).

− Refer the patient to the diabetes care team for management and education.

component of care continuity.

http://www.ndep.nih.gov/resources/index.aspx

http://www.jdrf.org/index.cfm?page_id=103431

http://www.diabetes.org/campaigns/american-diabetes-association-type2-diabetes.html?utm_source=WWW&utm_medium=FooterSlider4&utm_content=LWT2D-program-dec2011&utm_campaign=LWT2D



Appendix

Click to view or print pdf.

http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/AlgorithmDiagnosisType1Diabetes.pdf



Table 5 – Risk Factors to Consider For Type 2 Diabetes in Asymptomatic Children

Table 5 – Testing for type 2 diabetes in asymptomatic children

Criteria • Overweight (BMI >85th percentile for age and sex, weight for

height >85th percentile, or weight >120% of ideal for height Plus any two of the following risk factors:

• Family history of type 2 diabetes in first- or second-degree relative

• Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)

• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS, or birth weight small for gestational age birth weight)

• Maternal history of diabetes or GDM during the child’s gestation

Age of initiation: 10 years or at onset of puberty, if puberty occurs at a younger age Frequency: every 3 years PCOS, polycystic ovary syndrome Source: 2012 Position Statement from the American Diabetes Association (ADA), Standards of Medical Care in Diabetes

(Click to view or print pdf.)


http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/Table5.pdf



Questions about Symptoms

Example Questions to Ask When Considering a Diagnosis of Diabetes 1. Has your child been urinating more frequently in the past few weeks? 2. Has your child been thirstier recently? 3. Has your child started wetting the bed or voiding at night recently? 4. Has your child been vomiting recently?




Key Activity: Identify and Communicate with Multidisciplinary Care Providers

Rationale: Successful diabetes management requires the identification of a multidisciplinary team and frequent, bidirectional communication among all members. Such communication will serve to improve the quality of care provided and health outcomes. In the absence of clear role identification, care coordination, and bidirectional communication, important diabetes-related problems can be overlooked, patient safety can be compromised, and costs of care can increase unnecessarily—for example, with emergency department visits and/or hospitalizations for acute diabetes-related issues rather than planned care.


Gap: Care team members necessary to manage the child’s diabetes and general health surveillance are not identified in the medical record.

Physicians and staff members are unaware of the important role the multidisciplinary team plays in diabetes management. Rather, they focus on their specific responsibilities within the care team.

• Review the guidelines that outline the screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes:









• Discuss the following with staff:

The individual roles of the pediatrician and the diabetes team and the importance of a team-based approach to diabetes management

The substantial impact that diabetes has on families and ways to mitigate such impacts with collaborative care that is coordinated among all stakeholders in the child’s care

• Review and consider sharing with staff:

Materials for Pediatric Subspecialists within the Medical Home on the AAP National Center for Medical Home Implementation Web site, featuring news, articles, best practices, resources, and links for subspecialty care

Katz ML, Laffel LM, Perrin JM, Kuhlthau K. Impact of type 1 diabetes mellitus on the family is reduced with the medical home, care coordination, and family-centered care J Pediatr. 2012 May;160(5):861-867.













http://www.medicalhomeinfo.org/how/care_delivery/pediatric_subspecialists.aspx

http://www.medicalhomeinfo.org/how/care_delivery/pediatric_subspecialists.aspx






The patient’s pediatrician is not documented in the medical record—either due to lack of documentation or because the patient does not have an ongoing relationship with a pediatrician.

• Create processes that require staff to confirm at the patient’s medical record has an up-to-date name and address of the patient’s pediatrician. This might include having the front desk ask and record the name of the pediatrician at the time of check-in (along with insurance information) or having a prompt in the clinic visit template. It might also include conducting an annual audit to ensure all patient information is accurate and up-to-date.

• Review with the patient and family the importance of developing an ongoing relationship with a pediatrician in the medical home for new and ongoing health concerns. Recommend that the patient receive their health supervision visits and immunizations from their medical home. In addition, the medical home generally provides the insurance referrals for the diabetes specialty visits.

• Once identified in the medical record, refer the patient to the pediatrician for regular health supervision visits, sports physicals, and recommended immunizations, including an annual flu shot. Also refer the patient to the pediatrician when calls about non-diabetes-related issues are received. Encourage open communication channels between the pediatrician and the diabetes team so that each can contact the other to share important information or to assist with diabetes specific issues at the time of intercurrent illnesses or surgeries.

• Consult your AAP State Chapter for a directory of member pediatricians to use for referral purposes. (View the Chapter Contact List and Web sites, if needed, to find your state chapter.) Refer the patient to a pediatrician in close proximity to the patient’s home. This might include a designated pediatrician in the Health Department.

• If still no pediatrician appointment is made by the next diabetes specialty visit, offer to have the office staff schedule the appointment before the patient leaves the clinic.

• Enlist the help of the diabetes educator or a social worker to help connect families to needed resources.

The patient’s diabetes subspecialist (pediatric endocrinologist) or other multidisciplinary care team members are not identified in medical record or information is not kept up-to-date.

• Develop processes to identify and update the patient’s care team name and contact information at every visit. Consider the following:

Establish clear roles and responsibilities for obtaining such contact information and identify a clear place in the patient’s medical record to record the information.

Train staff to check for missing or erroneous information and to update name and contact information at every visit. Also train staff to watch for any returned correspondence or failed faxes and make necessary corrections.

• Discuss obstacles for identifying and/or documenting the care team members with clinicians and staff, then brainstorm and implement ways to overcome the obtstacles.

• Recognize that without adequate documentation, important diabetes management information cannot be communicated and appropriate follow-up may not take place.




http://www2.aap.org/member/chapters/chaplist.cfm

http://www2.aap.org/member/chapters/chaplist.cfm




Engage the patient/family to keep physician contact information up-to-date and readily available for all health visits. The My Medical Support Team worksheet included in this EQIPP course can help patients/families do this. Other online tools such as these on the Health Record Resources Web site are available to help patients and family keep their own ongoing personal health history.

• Establish clear roles and responsibilities for obtaining such contact information and identify a clear place in the patient’s medical record to record the information.

• Train staff to check for missing or erroneous information and to update name and contact information at every visit. Also train staff to watch for any returned correspondence or failed faxes and make necessary corrections.

Patients with diabetes and their families often have comorbid clinical conditions, financial concerns, social and cultural barriers, and emotional and mental health needs. They need to be connected to a wide range of community resources, which can require an overwhelming amount of time and effort.

• Consider the kinds of community resources and supports your practice and families would find useful. Then create, maintain, and consistently update a community resource list so the names and numbers are readily available to distribute to patients/families. Consider posting helpful resource information on your practice’s Web site.

• Enlist the help of the diabetes educator or a social worker to connect families to needed resources.

• Enlist the help of a psychologist or social worker to address the psychosocial needs of the patient and family.

• Refer the patient to the social worker to help arrange for needed resources.

The patient does not follow up with referrals.

• Make the referral appointment for other service providers while the patient is in the clinic. Help the patient identify any potential barriers for keeping the appointment and to find solutions. For example, if transportation is an underlying problem, suggest Medicaid transport or other available services.

• Brainstorm ideas with other members of the multidisciplinary team to help patients and families keep follow-up appointments.

• Involve social services as needed to help patients/families overcome barriers for keeping needed appointments.

• Copays may add an additional burden for financially strapped families; identify nonintimidating ways to inquire about financial strains. Then enlist the help of a social worker or case manager to connect families to needed resources.

http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/medicalsupportteam.pdf


http://healthrecordresources.com/build_your_personal_health_history.php




Gap: Essential diabetes care and management parameters are not communicated to the pediatrician or other care team members on a regular basis. (It is the subspecialist’s responsibility to develop, maintain, and share essential information about the plan of care.

It is the pediatrician’s responsibility to obtain and support the care plan and to communicate important health status changes.) There is no process in the subspecialist office for communicating the current care and management parameters to all team members. Or, there is no process in the pediatrician office for obtaining the patient’s care and management parameters or for communicating important health status changes to all team members.

• Establish a practice protocol that defines who is responsible for communicating the patient’s current care and management parameters and important health status changes; when such communication should occur; and whom should be included:

The patient and family The pediatrician in the medical home Pediatric endocrinologist and other subspecialists Other care team members essential to the disease management

process (for example, registered dietician, school personnel, trained mental health professional)

• Create systems to document that mail or secure electronic communication has occurred between the diabetes team, the pediatrician, and other team members.

• Encourage the patient/family to play a role in communicating changes in health status and care regimen to all members of their medical support team. It is important for the patient/family to know when to see which doctor and for what and to be able to contact them. The My Medical Support Team worksheet included in this EQIPP course can help patients/families do this.

• Discuss with staff the importance of regular communication with all care team members that accurately and completely reflects the care provided to the patient. Quality communication and documentation are essential components of care continuity.

• Meet with staff members who are not fulfilling their communication responsibilities to patients’ medical homes and troubleshoot why this is happening. Brainstorm any obstacles and ways to overcome them. Conduct Plan, Do, Study, Act (PDSA) cycles using the ideas presented by the group.

It is not clear what needs to be regularly communicated to the patient’s pediatrician and other identified team members.

• Establish a practice-wide protocol to communicate essential diabetes care and management parameters to the patient’s pediatrician and other identified team members every 6 months at a minimum or more frequently as needed. Use the Diabetes Care and Management Parameters Checklist below or adapt it for your purposes and electronic health record (EHR) to remind staff to communicate these essential parameters on a timely basis.

Diabetes Care Parameters

Check if communicated at least twice in past 12 months or more frequently as needed 1. Measures of growth and development including body mass

index (BMI) and Tanner staging

• Periodically audit your communication frequency and approach with the patient’s pediatrician and other identified team members to seek out areas for improvement. Seek input from all identified parties on how the communication process can be improved and implement suggested ideas.



http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/DiabetesCareAndManagementParameters.pdf

http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/DiabetesCareAndManagementParameters.pdf



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? 2. Blood pressure measurements 3. Diabetes treatment program, including insulin regimen and

all diabetes-related medications 4. Measures of glycemic control (A1c and glucose self-

monitoring results) 5. Report of acute diabetes-related complications

(hypoglycemia and/or DKA) 6. Screening for chronic complications and co-morbidities of

diabetes including psychosocial issues Note: If screening results for co-morbidities are abnormal, they should be communicated immediately upon identification.

Diabetes Management Parameters Check if communicated at least twice in past 12 months or

more frequently as needed. 1. Visit frequency with the diabetes team; recommended

interval is quarterly 2. Frequency and adherence with daily blood glucose

monitoring 3. Daily insulin injection frequency or pump use, including

basal insulin as percent of daily insulin, bolus dosing, and U/kg/day

4. Adherence with pre-prandial administration of rapid- or short-acting insulin

There is a concern about reimbursement for care coordination activities, which do not involve face-to-face patient interaction.

• Consult coding tips in the following resources:

• The AADE guide, Diabetes Education Services: Reimbursement Tips for Primary Care Practice, provides coding tips for appropriately billing for diabetes self-management training and includes commonly used codes. A webcast of this information is also available.

The AAP Medical Home Coding Fact Sheet, updated annually

• Coding for Pediatrics 2012. American Academy of Pediatrics

• AAP Pediatric Coding NewsletterTM Online (requires subscription)

• AAP Coding Hotline, 1-800-433-9016 x-4022

• Bring the concern to the attention of the practice diabetes care champion, if one exists in your practice, and brainstorm both the problem and possible solutions. This person can obtain the necessary support to drive improvement and spread it throughout the practice.

• Conduct periodic coding sessions for staff to ensure understanding of correct codes. Conduct periodic audits to ensure coding procedures are followed correctly.

• Consult with other practices for reimbursement tips.

http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf


https://aade.adobeconnect.com/_a754148722/reimbursementtips

http://www.medicalhomeinfo.org/downloads/pdfs/MedicalHomeCodingFactSheet.pdf

http://ebooks.aap.org/product/coding-for-pediatrics-2012

http://coding.aap.org/newsletterarchive.aspx




• Consider an onsite review by a coding specialist.

• Review approaches to document counseling efforts to allow for billing according to time spent with patient/family (can bill according to time when 50% or more of the visit time is spent in counseling—which is a major component of diabetes visits to ensure adherence).




Key Activity: Identify and Address Psychosocial Issues

Rationale: Assessment of psychological and social issues is an important part of the ongoing management of diabetes. Psychosocial adjustment, cohesive family goals, meeting the daily demands of intensive management, and regular medical monitoring are important for achieving glycemic control and maintaining optimal quality of life.


Gap: Psychosocial issues are not evaluated at every visit, as appropriate.

Clinicians are unaware of their potential contributions concerning psychosocial assessment and care in patients with diabetes.

• Review the policies that outline clinicians’ responsibilities for diabetes care, including psychosocial assessment and counseling/care:









• Discuss with clinicians their responsibilities for psychosocial assessment and care and how they affect adherence and health outcomes. It may be important to assess barriers when rethinking the treatment regimen. These include psychological and social problems, which can impair the patient/family’s ability to carry out diabetes care tasks, thus compromising health status.

• Offer staff training periodically to discuss psychosocial assessment.

Clinicians do not remember to integrate the psychosocial assessment as part of the visit.

• Create a systematic procedure for assessing psychosocial issues—perhaps using a checklist of potential issues such as the example list of diabetes-related psychosocial issues provided in this EQIPP course or the Patient

• At the end of the visit, make it a practice to ask if the family understands and is satisfied with the plan discussed during











http://diabetes.eqipp.courses.testaap.org/File%20Library/DiabetesTools/120107_TES_Forms_Self-assessment_v2.pdf



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? Or, they forget to document the discussion.

Self-Assessment of Diabetes Concerns, Burdens, and Transition form from the AAP Endocrine Society Working Group on Transition. Keep the list or form in an accessible place and use it to confirm and document that important issues have been discussed. Or, adapt the list for your electronic health record (EHR) to complete and document such assessments as a part of routine care.

• Establish ways to identify and document patient and family concerns such as the following: Use a previsit questionnaire or prompts on the intake form to ask about

family concerns. For example, ask: − What concerns do you and your family have about managing life with

diabetes? − How do you feel you are doing in handling your diabetes? − In what ways has diabetes affected your everyday lifestyle? Or, for a

parent, “How has having a child with diabetes affected your family?”

Some patients may express this on a continuum, or scale of 1 to 10, to indicate they are doing great or they could be doing better. If less than optimal, ask what they could do to improve. Also consider using this technique to determine specific self-care behaviors such as monitoring blood sugar or following a meal plan or physical activity program.

Create various avenues for communication that allow patients and families to interact and communicate with the clinician via telephone, e-mail or possibly a patient portal for 24/7 Internet access.

• Train staff to recognize situations that present key opportunities for screening of psychosocial status, including: At diagnosis During regularly scheduled visits During hospitalizations When challenges of glucose control, quality of life, or adherence are

identified At discovery of complications

• In addition, be mindful of common life events such as divorce, financial stress, job change, death in the family, pre-adolescence and adolescence, or a change in schools that can interfere with ongoing diabetes management and add stress to families.

the visit, or if they have any additional concerns that might negatively impact their diabetes management.

• Develop a post-visit process. For example, the person who schedules the follow-up appointment could ask patients and families whether their concerns were addressed at this visit or if a plan was made to address them.

• Review with staff the need to document all family discussions to confirm they have been done. Discuss obstacles for consistent documentation and strategies to overcome such barriers.

http://diabetes.eqipp.courses.testaap.org/File%20Library/DiabetesTools/120107_TES_Forms_Self-assessment_v2.pdf




Clinicians do not feel equipped to assess psychosocial issues or they are uncomfortable doing so.

• Identify appropriate referral avenues and, when appropriate, refer patients to specialized behavioral medicine professionals who are specifically trained for psychological and social assessments and care and preferably have experience with childhood diabetes or childhood chronic disease.

Indications for referral to a mental health specialist familiar with diabetes management may include diabetes coping/adjustment concerns, noncompliance with medical regimen, depression (with or without the possibility of self-harm), anxiety, eating disorder, cognitive functioning that significantly impairs judgment or adherence, recurrent DKA, worsening metabolic control, or fear of hypoglycemia, among other issues.

• Involve the diabetes educator and other members of the multidisciplinary diabetes team in the assessment process. Families often have varying comfort levels with different care team members, so they may be more willing to share their challenges with another team member.

• Provide skill-building training to effectively assess psychosocial issues. For example, offer post-graduate training seminars by experts in behavioral health that review approaches to discussing psychosocial issues with motivational interviewing practice. Seek out CME/CEU opportunities focused on the issues of behavioral health.

• Discuss with your multidisciplinary care team ways to use emotional and behavioral health tools and how to interpret results. Administration and scoring should be completed by professionals or paraprofessionals that are familiar with testing procedures and with appropriate supervision.

Clinicians and other providers may think that if the patient’s diabetes is fairly well controlled, psychosocial assessments are not necessary.

• Make it a policy to assess psychosocial issues regularly, even in those patients with good control. Underlying issues may surface at any time and life events can interfere with ongoing diabetes management, which may impair the patient’s/family’s ability to carry out diabetes care tasks, thus compromising health status. It is important to remember that life with diabetes is difficult for most families.

• Keep assessing. Recognize that parents and other caregivers as well as patients can experience diabetes burnout. Understand that common life events such as divorce, financial stress, job change, death in the family, pre-adolescence and adolescence, or a change in schools can interfere with ongoing diabetes management and add stress to even the most balanced and highly functioning of families.

There is not enough time in the visit to discuss psychosocial concerns.

• Identify patients/families needing one-on-one counseling and make appropriate referrals immediately.

• Establish a protocol in which the diabetes educator also addresses psychosocial concerns when meeting with families.

• Revisit the scheduling system to ensure adequate time is allotted to appointments for dealing with psychosocial issues. Offer an extra visit to specifically discuss the patient’s psychosocial issues and barriers to

• Consider alternative communication methods—phone or e-mail, for example—in between visits to discuss and address ongoing psychosocial concerns.

• Identify easy- to-use survey tools to assess symptoms of depression, anxiety, and disordered eating



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? achieving treatment goals, if needed.

• Consider support groups to provide a forum for families to discuss their concerns with trained mental health providers.

behaviors; determine if there is a staff member available to interpret the results.

• Consider including psychological/ behavioral services as a standard component of multidisciplinary clinic care. Establish a protocol in which these team members administer and interpret brief mood, adjustment, and/or quality of life-screening measures in clinic.

• If available, consider requesting a psychology/behavioral consultation during hospital admissions to enhance coping, adjustment and/or adherence.

There are concerns that the practice will not be reimbursed for services provided.

• Document the time spent counseling during the appointment. Counseling services add to visit time and increase the level of service for billing purposes. Practices can bill based on time if 50% or more of the visit is spent in counseling—a common occurrence in pediatric diabetes care.

• Review the following coding resources to determine if your practice is coding appropriately:

The AADE guide, Diabetes Education Services: Reimbursement Tips for Primary Care Practice, provides coding tips for appropriately billing for diabetes self-management training and includes commonly used codes. A webcast of this information is also available.

Coding for Pediatrics 2012. American Academy of Pediatrics (available for purchase)

AAP Pediatric Coding Newsletter Online (requires subscription; check out the sample issue))

AAP Coding Hotline, 1-800-433-9016 x-4022

• Consult with a coding expert to review approaches to documenting billing according to time and counseling.

• Conduct periodic coding sessions for staff to ensure understanding of correct codes. Conduct periodic audits to ensure coding procedures are followed correctly.

Clinicians assess psychosocial issues but do not address them.

• Inform and educate patients and families about the psychosocial issues identified. As appropriate, offer possible strategies/counseling or refer the patient to a mental health professional trained to treat the patient’s psychological issues.

See the content for Identify and Address Psychosocial Issues in the Clinical

• If the referral appointment is not made by the next visit, offer to have the office schedule the appointment before the patient leaves the clinic.

• With family consent, maintain routine








Potential Barriers Suggested Ideas for Change Still Not Seeing Results? Guide of this EQIPP course for helpful strategies and resources for the psychosocial issues identified in the list. Also see Do You Have Questions? handout from the AAP Endocrine Society Working Group on Transition, which provide links for patients and families to learn more about diabetes and various topics of patient concerns.

• Recognize that in some cases, a referral is the most appropriate action to take. Indications for referral to a mental health specialist familiar with diabetes management may include diabetes coping/adjustment concerns, noncompliance with medical regimen, depression (with or without the possibility of self-harm), anxiety, eating disorder, cognitive functioning that significantly impairs judgment or adherence, recurrent DKA, worsening metabolic control, or fear of hypoglycemia, among other issues.

• Develop a system to ensure that a referral appointment is scheduled and treatment is initiated.

• Communicate the issues and mental health referral, if made, to the patient’s pediatrician.

• Document all issues, family discussions, referrals, and follow-up in the medical record.

communication and coordination of care with collaborating mental health professionals.

• Access psychological/behavioral services available in different settings.

Clinicians are experiencing diabetes burnout.

• Discuss difficult patient/family issues with staff and colleagues.

• Consider meeting with the clinic’s mental health counselor to help deal with stressful issues.

• In a multidisciplinary team staff meeting, have all members share a case for discussion.

• Arrange ongoing skill-building sessions with experts for guidance.

http://diabetes.eqipp.courses.testaap.org/File%20Library/DiabetesTools/120107_TES_Forms_Questions_v2.pdf



Appendix

List of Diabetes-Related Psychosocial Issues Among others, identify and address the following psychosocial issues based on the patient’s age, patient/family requests, and clinical indications founded on your team’s assessment: 1. Coping with diabetes 2. Family involvement in diabetes management 3. Nonadherence 4. Peer concerns 5. Anxiety and depression 6. Diabetes burnout 7. Disordered eating behaviors 8. Fear of hypoglycemia/hyperglycemia 9. Risk-taking behaviors such as drug abuse, alcohol, and tobacco use 10. Conception 11. Driving safety 12. Preparing for college 13. Communication with parents and with diabetes team 14. Transition to adult health care Note: This list is not intended to be an exhaustive inventory of psychosocial issues requiring surveillance, but rather some essential and practical issues common in pediatric diabetes care.




Key Activity: Review Individualized Diabetes Goals

Rationale: The goal-setting process gives patients and their families an opportunity to provide input about their diabetes self-care needs, goals, and priorities. Goal setting helps physicians and staff track progress and provide additional support to help patients reach their stated goals. In addition, coordination in goal setting between providers and patients/families helps improve outcomes. Staying healthy with diabetes requires effort on a variety of goals: healthy eating, exercise, medication adherence, diabetes monitoring, and balancing the sources and level of stress in one’s life. Most patients and families feel more confident about their efforts in some areas more than in others; thus, patient/family input for goal setting is important.


Gap: Individualized diabetes goals are not established or reviewed with the patient and family at every visit.

Clinicians and staff members are unaware of the value of setting diabetes goals at every visit, or the clinician’s responsibilities for leading this process.

• Review the policies that outline clinician’s responsibilities for diabetes care in the medical home. The patient and family, in full partnership and led by the diabetes care team, should develop individualized goals at each clinic visit. The diabetes care team is responsible for providing education and training to assist patients in reaching their individualized goals. The 2012 Position Statement from the American Diabetes Association

(ADA), Standards of Medical Care in Diabetes The AAP policy, Type 2: Clinical Practice Guideline for the Management of

Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents. (Check back for link; anticipated release early 2013.)




• Review the policies that outline responsibilities for coordination of care between the pediatric medical home, the diabetes care team, and other providers as an important component of high-quality care: The 2002 AAP Medical Home Policy Statement (reaffirmed 2008) The 2012 AAP policy statement, Patient- and Family-Centered Care and

the Pediatrician's Role

• Discuss with staff the complex nature of diabetes care with staff and the importance of addressing many issues beyond glycemic control in order to improve health outcomes.

• Explain how the goal-setting process helps improve outcomes as patients and their families provide direct input about their diabetes self-care needs, goals, and priorities.














Clinicians and staff members have difficulty engaging patients and families in the goal-setting process. Or, they have not had motivational interview training or acquired other skills needed for effective behavioral therapy.

• Ensure that designated personnel (ideally diabetes education team members) are comfortable with the process of goal setting, including training in motivational interviewing, and schedule adequate patient time for this purpose.

• Develop motivational interviewing skills from sources such as: Motivational Interviewing Training Video: A Tool for Learners (Hettema,

2009), a motivational interviewing skills development series for clinicians Miller WR, Rollnick S. Motivational Interviewing: Preparing People for

Change. 2nd Ed. New York: Guilford Press; 2002. Rollnick S, Miller WR, Butler CC. Motivational Interviewing. In: Health Care:

Helping Patients Change Behavior. New York: Guilford Press; 2008. Schwartz RP. Motivational interviewing (patient-centered counseling) to

address childhood obesity. Pediatric Annals. 2010;39:154-158.

• Refer patients to mental health professionals versed in pediatric diabetes management issues, as appropriate.

The patient or family is not interested in setting individualized diabetes goals because they do not see value in the process or do not want to change current behaviors or practices.

• Use techniques such as the following when talking with patients about improving their diabetes health: Ask open-ended questions to determine underlying concerns and issues.

For example, “What kind of problems with your diabetes have you been having recently?” Then, follow up with more detailed questions based on their response.

Pay attention to body language that might convey a resistance to adherence or confusion about diabetes management.

Use motivational messaging to help the patient/family visualize the benefits of good diabetes management. For example, ask questions like: “If you were to improve your blood sugar control, what might be some benefits?”

Show authentic interest in the challenges the patient/family faces as they attempt to achieve better diabetes management. Be empathetic and encourage those with previous failed attempts.

• Encourage patients to identify at least one diabetes-related health issue they would like to change or improve and start with that. The AADE7™ Self-Care Behaviors provide an evidenced-based framework for good diabetes management centered around seven diabetes self-care behaviors:

1. Healthy eating 5. Problem solving 2. Being active 6. Reducing risks 3. Monitoring 7. Healthy coping 4. Taking medication

• Use motivational messaging, encouragement, and education to stress the need

• Provide linkages to community resources that include peer-to-peer support (especially for adolescent patients) and family support.

• Help the patient/family recognize that consistently perfect diabetes management is impossible. Encourage them when they are having trouble with one part of their diabetes self care to not give up, but rather to seek help and support.

• Involve other members of the multidisciplinary diabetes team, including behavioral health specialists, to work with the patient/family regarding the importance of goal setting with attention to realistic goals.

http://www.mitrainingvideo.com/



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? for goal setting with patients/families. Explain the link between adherence to diabetes management tasks and glycemic control as well as the link between glycemic control and overall health outcomes.

• Avoid discussions of poor future health in a way that appears to be a threat or an inevitable outcome of current actions. Such approaches are rarely successful in pediatric care. It is best to cast discussions of complications in an educational tone.

Clinicians and staff members have difficulty helping patients and families write effective diabetes self-management goals.

• Consider these four basic steps for helping patients set individualized diabetes goals:

1. Identify an area for improvement. 2. Write an effective goal. 3. Develop a realistic plan to implement the change. 4. Review progress and provide feedback.

• Incorporate goal setting as a natural part of the visit. After checking blood sugar, for example, ask the questions, what will you do to achieve your goal for better blood sugar control?, how much will you do this?, when will you do it?, and, how often will you do it?

For example, Using my cell phone alarm to remind me, I will check my blood sugar (what) twice a day (how much) before breakfast and dinner (when) every day (how often).

• Help patients and families evaluate what they have written to make sure the goal is SMART: Specific, Measurable, Achievable, Realistic, and Timely.

• Have patients and families work with the diabetes educator to help them formulate diabetes self-management goals.

You do not have a process for incorporating goal setting into the visit.

• Discuss with your team the importance of goal setting to build skills that are needed for successful diabetes management. Realize that goals are constantly changing and often evolve over the course of a number of clinic visits, not just one.

• Develop a system for your practice that routinely allows for diabetes goal setting at every visit. Consider these strategies: Limit goal setting to one or two diabetes-related health issues the

patient/family would like to change or improve, and start with that. Consider alternate communication methods—e-mail or text messages, for

example. Offer an extra visit only for goal planning, if needed. Encourage patients and families to take responsibility for thinking about

ways to improve diabetes control and for implementing such improvements.

Flag the medical record when goal setting does not occur at this visit to ensure that appropriate time is allotted at the next visit. Work with a peer or colleague in experimenting with the goal-setting process. Collaboration can help effectively link patient diabetes management and instructional approaches for the purpose of continuous improvement.



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? Ask the patient/family to write a goal on the Diabetes Goals Worksheet and

either turn it in at the front desk, mail it to the office, or bring it to the next appointment. Follow these helpful tips:

1. Help patients and families identify their top area for improvement and a specific goal for change. Changing many things at once can be overwhelming and result in failure and discouragement. It may be better to install one new goal at a time, get that new goal running on autopilot, and then work on the next goal.

2. Write a goal statement in complete detail. Writing it down creates a roadmap to success. Make sure the goal statement answers the questions: what?, when?, how much?, and how often?

3. Help evaluate the goal to be sure it is SMART: Specific, Measurable, Achievable, Realistic, and Timely.

4. Ask patients and families to assess their confidence in achieving their stated goals and to identify any help or resources needed. Also ask them to consider any social support they need from family, friends, the school nurse, community support, or others.

5. Provide any identified information, education or resources to help patients achieve their stated goal. Patient resource handouts for each AADE7™ self-care behavior may be downloaded from the Diabetes Educator website. These handouts provide basic information for each of the seven areas and include facts, tips, advice and activities. They are available in both English and Spanish.

6. Use the Notes section of the worksheet to date and document all family discussions, resources and education provided, and referrals.

7. Give the patient/family a copy of the worksheet and place a copy in the medical record.

8. Follow up on goals for attainment of progress at the next visit. Modify existing goals as needed or identify and prioritize new goals. Diabetes management requires continuous improvement.

9. Document all follow-up activities and accomplishments in the Notes section.

10. Communicate patient goals and coordinate care with team members in a clear and timely manner.

Clinicians and staff members may be hesitant to extend the visit time for goal-setting

• Consult coding tips in the following resources: AADE guide, Diabetes Education Services: Reimbursement Tips for

• Bring the concern to the attention of the practice diabetes care champion, if one exists in your

http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/DiabetesGoalsWorksheet.pdf

http://www.diabeteseducator.org/DiabetesEducation/Patient_Resources/AADE7_PatientHandouts.html




Potential Barriers Suggested Ideas for Change Still Not Seeing Results? purposes because there is a concern about not being reimbursed for services.

Primary Care Practice, provides coding tips for appropriately billing for diabetes self-management training and includes commonly used codes. A webcast of this information is also available.

AAP 2012 Coding for Pediatrics (available for purchase) AAP Pediatric Coding Newsletter Online (requires subscription) AAP Coding Hotline, 1-800-433-9016 x-4022

practice, and brainstorm both the problem and possible solutions. This person can obtain the necessary support to drive improvement and spread it throughout the practice.

Clinicians and staff members find it difficult to confer about goal setting when patients have immediate and pressing medical concerns to attend to during the visit.

• Develop a system for your practice that routinely allows for diabetes goal setting at every visit. This may require a phone call to the home or delaying the goal setting to a separate encounter at a time when medical concerns are not pressing.

• Alternatively, personnel less involved with the immediate medical management issues might be designated to address or assist with the goal-setting process. For example, an educator might encourage one parent to take responsibility for insuring that the evening dose of insulin is given every day for one month, and this goal might be set simultaneously as the physician is arranging admission to the ICU for DKA.

• Flag the medical record when goal setting does not occur at this visit to ensure that appropriate time is allotted at the next visit.

Diabetes goals are discussed at the visit, but are not documented.

• Discuss with staff the importance of documentation, both for care continuity and billing purposes. Remember the adage: “If it’s not documented, it was not done.”

• Give the patient/family a copy of the written goals and keep a copy in a consistent, easily accessible location in the medical record.

• Create a Notes section to identify follow-up actions and timeframes.

• Brainstorm with staff any obstacles for lack of documentation and ways to overcome them.

• Put necessary checks and balances in place to ensure documentation is complete.

Goals are set, but not reviewed for attainment of progress at the following visit.

• Incorporate a system reminder or prompt to ensure that goals are reviewed at every visit. For example, place a copy of the Diabetes Goals Worksheet in the medical record to trigger follow-up at the next visit. Put necessary checks and balances in place to ensure follow-up is complete.

• Establish a patient flow that includes time for asking how the patient is doing with the goals set at the last appointment—for example, at the start of the patient visit or following the physical examination time.

• Discuss with staff the importance of reviewing progress toward goals after they have been set. A review of prior goals provides an opportunity to give feedback, problem-solve if needed, acknowledge progress made, and make a new action plan with higher or different goals.

• Brainstorm with staff any obstacles causing a lack of goal review and ways to overcome them.





http://diabetes.eqipp.courses.aap.org/File%20Library/DiabetesTools/DiabetesGoalWorksheet.pdf




Key Activity: Provide Multidisciplinary Diabetes Education and Self-Management Training

Rationale: There is increasing evidence that a multidisciplinary team approach to the care of patients with diabetes is associated with better outcomes. Such an approach combines clinical, educational, and psychological expertise to improve health outcomes. The ideal multidisciplinary team should be composed of members who have pediatric diabetes expertise and include, but not be limited to: a pediatric endocrinologist, pediatrician, diabetes educator or diabetes nurse practitioner, professional credentialed as a registered dietician/nutritionist, trained mental health professional, social worker, and school personnel. All members of the multidisciplinary team contribute to and play unique and important roles in the patient/family’s diabetes education and self-management training, an ongoing facilitation of the knowledge and skills necessary for diabetes self-care. It includes education about behaviors such as healthy eating, being active, monitoring blood sugar control, taking medication, problem solving, healthy coping, and reducing health risks.


Gap: Diabetes education and/or self-management training are not regularly provided to patients and their families.

Clinicians and staff are unaware of their potential contributions in providing multidisciplinary diabetes education and self-management training for the prevention or delay of diabetes-related complications.

• Review the policies that outline the clinician’s responsibilities for diabetes education and self-management training as part of the medical management of diabetes: The 2012 Position Statement from the American Diabetes Association

(ADA), Standards of Medical Care in Diabetes The AAP policy, Type 2: Clinical Practice Guideline for the Management

of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents (Check back for link; anticipated release early 2013.)







• Discuss the complex nature of diabetes care with staff and the importance of addressing many issues beyond glycemic control in order to improve health outcomes. Review the ways education and training can help support favorable health outcomes of patients with diabetes.














Potential Barriers Suggested Ideas for Change Still Not Seeing Results? The 2002 AAP Medical Home Policy Statement (reaffirmed 2008) The 2012 AAP policy statement, Patient- and Family-Centered Care and

the Pediatrician's Role

Clinicians do not make education part of the visit or they do not document such discussions.

• Ensure that a multidisciplinary diabetes team approach exists with defined roles for a certified/eligible educator or nutritionist and physician.

• Brainstorm ways to make education a systematic part of every patient visit built into regular prevention activities and other teachable moments such as during physical examination, growth measurements, and blood pressure checks. Also discuss obstacles and ways to overcome them.

• Ensure there is sufficient time during the session for appropriate diabetes education relevant to the day’s visit.

• Make sure that an administrative system is in place that makes it easy to distribute educational materials. Assign a specific person(s) in the office to keep materials stocked.

• At minimum, a visit with a pediatric diabetes educator is recommended annually.

• In a staff meeting, gain understanding that services that are not documented may not have been done, and therefore, the practice will not be paid for them. Brainstorm about obstacles for consistent documentation and ways to overcome them.

Some staff members are not equipped as educators.

• Hire an appropriate number of certified diabetes educators. If this is not feasible, refer patients to one in your community. The American Association of Diabetes Educators (AADE) is a referral source.

• Provide skill-building training for staff to effectively deliver relevant education. • Have a checklist of education topics built into the EMR template that can be

checked off at each visit. For example, consider providing education around the following: Pathophysiology of diabetes Nutrition Pharmacological interventions Exercise Self-monitoring of blood glucose and interpretation of the data Insulin dose and food adjustment Prevention and management of acute and chronic complications Psychosocial adjustment Problem-solving skills Stress management Use of the health care delivery system

• Consider the benefits of having a diabetes advocate in your office. This person can be any staff member who is passionate about helping patients with diabetes live healthier lives and who can serve as a resource in your practice to help other staff members routinely and effectively address diabetes education and training with patients and families during the visit. Decide how to involve the diabetes advocate in your practice to help build relationships among all parties, coordinate information and follow-up, and identify community linkages and resources for support.




http://www.diabeteseducator.org/




• Keep diabetes education and skill training materials in an accessible place. Build a library of information and links to existing resources from sources such as the following: National Diabetes Education Program (NDEP) National Diabetes Information Clearinghouse (NDIC) American Diabetes Association (ADA) DiabetesPro Professional Resources Online American Diabetes Association of Diabetes Educators (AADE)

•

Some think that if a patient’s diabetes is fairly well controlled, education and training are not necessary.

• Make it a policy to regularly assess educational needs. All patients need continuing education as their schedules and activities change, and as they grow, mature, and take on new responsibilities. Common life events such as family divorce, financial stress, job change, death in the family, the approach of adolescence, or a change in schools can interfere with ongoing diabetes management. Patients and families should be well equipped with information to handle new stresses. Psychosocial issues should also be assessed.

• Ask the patient/family about any questions or concerns they have about managing their diabetes. Remain alert for changes in metabolic control and lifestyle changes that require additional education.

There is not enough time in the visit for patient education.

• Develop a protocol in your practice that designates an individual, typically a diabetes educator, to identify and provide key educational messages to patients/families, preferably at every visit.

• Use teachable moments discovered during history or physical examination to discuss issues requiring education.

• Brainstorm with staff about obstacles for creating and supporting an effective diabetes education program for all patients and ways to overcome them. Conduct Plan, Do, Study, Act (PDSA) cycles using the ideas presented by the group.

The practice cannot afford education materials.

• Download and print free diabetes education materials available from sources such as the following: National Diabetes Education Program (NDEP) National Diabetes Information Clearinghouse (NDIC) American Diabetes Association (ADA) DiabetesPro Professional Resources Online

• Visit your health department’s Web site. Many states offer free materials to health care providers.

• Use online educational resources from accredited organizations such as those mentioned at left.

• Create your own educational materials. Consult with other practices and coalitions about educational materials they are using and adapt them for your purposes.

There are concerns that the practice will not be reimbursed for educational services provided.

• Document all services for medical decision making or care coordination including phone calls and correspondence. Both can be a financial drain in a practice with many patients requiring chronic condition management. Use a tracking sheet to keep track of time spent on non–face-to-face care.

• Counseling services can add to visit time and increase the level of service for billing purposes. Document the time spent counseling during the appointment.

• Conduct periodic coding sessions for staff to ensure understanding and application of correct codes.

http://ndep.nih.gov/resources/index.aspx

http://diabetes.niddk.nih.gov/

http://www.diabetes.org/

http://professional.diabetes.org/ResourcesForProfessionals.aspx?typ=17&cid=60378

http://ndep.nih.gov/resources/index.aspx

http://diabetes.niddk.nih.gov/

http://www.diabetes.org/

http://professional.diabetes.org/ResourcesForProfessionals.aspx?typ=17&cid=60378



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? Recall options for billing based on time if 50% or more of the visit is spent in counseling, which is common in the care of pediatric diabetes.

• Review the following coding resources to determine if your practice is coding appropriately: The AADE guide, Diabetes Education Services: Reimbursement Tips for

Primary Care Practice, provides coding tips for appropriately billing for diabetes self-management training and includes commonly used codes. A webcast of this information is also available.

AAP 2012 Coding for Pediatrics (available for purchase) AAP Pediatric Coding Newsletter Online (requires subscription) AAP Coding Hotline, 1-800-433-9016 x-4022









Key Activity: Demonstrate Ongoing Diabetes Monitoring (Primary Audience: Subspecialist; Secondary Audience: Generalist)

Rationale: Maintenance of health in children and youth with type 1 diabetes mellitus requires ongoing education, assessment of clinical and laboratory measures of diabetes control, and age-appropriate healthy lifestyle. Growth and development, blood pressure, insulin administration, and blood glucose monitoring techniques, as well as measures of diabetes control, including HbA1c and blood glucose, should be assessed during quarterly visits to the diabetes care team. Treatment of abnormal findings and education regarding insulin and dietary needs during these visits should be focused on decreasing the risk of complications.


Gap: All ADA-recommended diabetes assessments are not completed within the suggested timeframes.

Staff members are unaware of clinician’s responsibilities and suggested timeframes for ongoing diabetes monitoring.

• Review the policies that outline clinicians’ responsibilities for diabetes care:









• Establish a practice-wide protocol that includes the ADA-recommended diabetes assessments and suggested timeframes such as those identified in the Type1 and Type 2 tables for this EQIPP course. Adapt for your electronic

• Discuss with staff the importance of ongoing monitoring to achieve and maintain blood glucose control and monitor for complications and comorbidities.

• Review the recommended assessments and timeframes that support favorable health outcomes of patients with diabetes.













Potential Barriers Suggested Ideas for Change Still Not Seeing Results? health record (EHR)] to remind staff to seek out completion of assessments on a timely basis. Periodically audit the protocol to ensure it is up-to-date and that staff members use it consistently and correctly.

Patients/families are not keeping appointments—perhaps because of one or more of the following reasons: • They do not recognize or

value the importance of ongoing diabetes care.

• They have limited access to care, including financial (lack of insurance coverage or inability to take time off from paid employment), transportation, other care-taking responsibilities, or conflicts with parents’ work schedules and/or child’s school/activity schedule.

• Set up a registry or other system that tracks patients who are not being seen regularly. Designate a staff member to reach out to these patients/families to make appointments.

• Educate patients/families about the importance of ongoing monitoring to achieve and maintain blood glucose control and monitor for complications and comorbidities. Review the recommended assessments and timeframes that support favorable health outcomes of patients with diabetes.

• Consider ways to improve access to care within the practice—for example, additional evening or Saturday appointments.

• Direct patients/families to seek social service support for transportation, visiting nurse, home health, respite, or other needed services that are limiting access to care.

• Provide school with medical and legal rationale for need to miss school for appointments (see NDEP School guide, Helping the Student with Diabetes Succeed: A Guide for School Personnel).

• Refer patients/families with psychosocial issues for counseling. Consider cognitive behavioral therapy, if available.

• Communicate with the patient’s pediatrician to enlist aid in attempting to improve adherence.

Patients’ elevated blood pressures are not consistently identified and/or are not documented. (Diet and exercise modifications recommended if above 85% on two additional occasions; pharmacological therapy recommended if above 95% on two

additional occasions despite diet and exercise modification for 3 to 6 months.

The responsibility for blood pressure measurements within the practice is not clear. Or, staff forgets to complete task. Or, measurements are inaccurate. Or, age-related normal guidelines are not readily available during the visit.

• Establish a patient flow for your office that delineates clear responsibilities for key activities in the patient visit, including growth and blood pressure measurements, in the order they should occur. Putting these steps in a visual flow map may help you see bottlenecks or unnecessary motions.

• Standardize the process so that staff members follow the same steps every time, eliminating the need for guesswork about who does what and when.

• Make sure the examination room is stocked with blood pressure equipment and age-related normal guidelines readily available. Use the following tools:

Blood Pressure Tables for Children and Adolescents from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (or see the full Fourth Report)

Pediatric On Call blood pressure calculator

• Have a flow sheet in chart that is filled in and reviewed at each visit for growth parameters and vital signs.

• If not filled in, have assigned personnel complete the task before the patient leaves.

• Review flow sheets and personally check elevated blood pressures (based on age-related norms) manually at visits.

http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=97#main

http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=97#main

http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.pdf

http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf

http://www.pediatriconcall.com/fordoctor/pedcalc/bp.aspx




Blood pressure levels for boys and girls by age and height percentile from PediatricHypertension.org

CDC BMI Percentile Calculator for Child and Teen

Children's BMI-percentile-for-age Calculator from the USDA/ARS Children’s Nutrition Research Center at Baylor College of Medicine

• Clinical growth charts: CDC Table for Calculated Body Mass Index Values for Selected Heights and Weights for Ages 2 to 20 Years Make certain blood pressure and age, height, and gender percentiles are reviewed in EMR at each visit.

• Make sure percentiles are available or incorporated into the patient’s medical record.

Blood pressure measurements are not documented in patient charts.

• Involve the team in determining the reasons for lack of documentation and identifying possible solutions.

• Institute a flow chart for blood pressure, height, weight, BMI, and A1c and review before the patient leaves the office. Designate the responsibility for documenting blood pressure measurements to specific staff members.

• Periodically audit patient records to ensure that documentation is thorough and complete.

• Review with staff the importance of blood pressure monitoring in patients with diabetes, including increased risk of heart disease and eye, kidney, and nerve complications.

• Check flow charts at each visit.

Appropriate action for elevated blood pressure is not taken or actions are not documented.

• Establish a practice-wide protocol for blood pressure monitoring that considers the following:

Include a chart of normative blood pressure based on sex, age, and height for pediatric patients in the medical record and plot at each visit.

Review patients’ blood pressure percentile and trends at each visit.

Have a flow chart with blood pressure recorded and actions taken for each visit.

Have the physician re-take patients’ blood pressure following identification of elevated blood pressure by the nurse using a manual monitor and the appropriate size cuff.

Monitor patients with elevated blood pressure closely to help ensure appropriate care and follow-up.

Address lifestyle management issues with patients having blood pressure less than 85 percentile for age, including discussions about weight status,

• Review with staff the importance of blood pressure monitoring in patients with diabetes, including increased risk of heart disease and eye, kidney, and nerve complications.

http://www.pediatrichypertension.org/BPLimitsChart0112.pdf

http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx

http://www.bcm.edu/cnrc/bodycomp/bmiz2.html

http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/00binaries/bmi-tables.pdf

http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/00binaries/bmi-tables.pdf



Potential Barriers Suggested Ideas for Change Still Not Seeing Results? salt intake, and exercise.

Treat with an ACE inhibitor if the patient’s blood pressure is consistently less than 95% percentile for 3 months or with an angiotensin receptor blocker (ARB) if the ACE inhibitor is not tolerated.

If treatment is not successful within 6 months, refer the patient to a hypertension specialist within the community (nephrologist/cardiologist).

Patients’ elevated lipids are not consistently identified and/or are not documented. (Diet and exercise modifications are recommended if elevated; pharmacological therapy is recommended if it is still elevated despite diet and exercise

modification for 3 to 6 months.

There are no lipid values for patients at the time of the visit—either lab tests are not completed or they are completed by an outside laboratory and the results have not been received by the diabetes team.

• If lipid values are obtained from an outside laboratory, obtain results and enter them into the patient’s medical record. Put procedures in place to obtain these values prior to the clinic visit. Consider the following:

Have the patient fax results to the office.

Provide a written reminder (on the previous visit) to obtain values for the next visit.

Determine the name of the patient’s approved laboratory and have staff call for lab results before the clinic visit.

If not constrained by insurance, obtain lipid panel during visit even if nonfasting. Reconfirm abnormal values with a fasting study.

• Address lifestyle management issues with patients having elevated lipids, including discussions about weight status, salt intake, and exercise.

• Address glycemic control—if poor, lipid levels are more likely to be abnormal.

• Review with staff the importance of having lipid values for appropriate treatment to be initiated.

• Clarify responsibilities of all staff to ensure staff know who is assigned to review the chart and call for outstanding lab tests ordered at the previous visit.

Appropriate action for elevated lipid levels is not taken or not documented.

• Create a flow chart in which to record lipid values at all appropriate visits and review with the patient and family.

• Establish a consistent place in the medical record for lipid results and management plan for abnormal results.

• Closely monitor patients with abnormal results to help ensure appropriate care and follow-up. Note: If LDL is greater than 160 mg/dl following 3 to 6 months of nutrition and lifestyle management, then treatment with a statin drug is recommended based on risk assessment. Before initiation of a statin drug, a pregnancy test should be obtained for females at risk for pregnancy.

• Review with staff the importance of monitoring lipid levels in patients with diabetes, including risks of macrovascular disease.




Patients’ elevated urine microalbumin levels are not consistently identified and/or are not documented. (Pharmacological therapy should be recommended if it is elevated on two separate occasions or on a first-morning void to avoid overdiagnosing orthostatic

microalbuminuria.)

Appropriate action for elevated urine microalbumin levels is not taken or not documented.

• Have urine microalbumin:creatinine ratios or albumin excretion rates listed on flow sheet and results documented at appropriate visits.

• Incorporate microalbumin:creatinine or albumin excretion rates results and actions for abnormal results in diabetes clinic note template.

• Closely monitor patients with abnormal results to help ensure appropriate care and follow-up.

• Address lifestyle management issues—especially discussions about weight status and glycemic control—with patients having elevated urine microalbumin levels.

• Check creatinine level and estimated glomerular filtration rate (eGFR) in individuals with microalbuminuria.

• If urine microalbumin levels are greater than 30, obtain spot urine microalbumin (using the first-morning void) on two additional occasions. If it is still abnormal and not tolerated by ARB, use ACE. Before initiation of ACE, a pregnancy test should be obtained for females at risk for pregnancy.

• Review with staff the importance of monitoring microalbumin levels in patients with diabetes, including increased risk of kidney complications as identified in the 2012 ADA Standards of Medical Care in Diabetes.





Appendix

Table of Recommended Assessments for Type 2 Diabetes and Frequency of Completion

Recommended Assessments for Type 2 Diabetes As identified in the ADA 2012 Standards of Medical Care in Diabetes*

Check if completed at recommended frequency

Frequency of Completion

Physical

Measures of blood pressure recorded and plotted on blood pressure chart Quarterly

Height, weight, and BMI measured and plotted on growth chart Quarterly

History

Medications and comorbidities Quarterly

Changes to diabetes regimen and medication doses Quarterly

Review of blood glucose values and, if patient is receiving injections, insulin administration records Quarterly

Laboratory

HbA1c Quarterly

Spot urine microalbumin:creatinine ratio or albumin excretion rates At onset and annually, or per clinical judgment Lipids At onset, annually, or per clinical judgment Liver function (AST and ALT) At onset and annually, or per clinical judgment

Treatment

Ophthalmologic referral for children At onset and annually

Recommend/provide inactivated influenza vaccine for children ≥6 months of age Annually

Nutrition consultation At onset and as clinically needed *Also see ISPAD Clinical Practice Consensus Guidelines, another source of consensus guidelines on the medical management of pediatric diabetes, which may differ slightly in its recommendations.





Table of Recommended Assessments for Type 1 Diabetes and Frequency of Completion

Recommended Assessments for Type 1 Diabetes As identified in the ADA 2012 Standards of Medical Care in Diabetes*

Check if completed at recommended frequency

Frequency of Completion

Physical

Measures of blood pressure recorded and plotted on blood pressure chart Quarterly

Height, weight, and BMI measured and plotted on growth chart Quarterly

Examination documenting presence or absence of lipohypertrophy and lipoatrophy Quarterly

History

Medications and comorbidities Quarterly

Changes to diabetes regimen and doses Quarterly

Review of blood glucose values and insulin administration records Quarterly

Laboratory

HbA1c Quarterly

Spot urine microalbumin:creatinine ratio or albumin excretion rates in children ≥10 years of age or younger with hypertension Annually, or per clinical judgment

Lipids Annually, or per clinical judgment Celiac screening When clinically indicated or per current

guidelines TSH screening At diagnosis and annually, or per clinical

judgment—eg, if thyroid is enlarged or thyroid antibodies are present

Treatment

Ophthalmologic referral for children ≥10 years of age and diabetes duration >3 to 5 years Annually

Recommend/provide inactivated influenza vaccine for children ≥6 months of age Annually

Nutrition consultation Annually *Also see ISPAD Clinical Practice Consensus Guidelines, another source of consensus guidelines on the medical management of pediatric diabetes, which may differ slightly in its recommendations.





Clinical Indications of Celiac Disease • GI symptoms • Unexplained hypoglycemia • Poor growth • Poor weight gain • Unexplained erratic glycemia




Key Activity: Recommend Appropriate Immunizations Primary Audience: Generalist (Pediatrician)

Rationale: Children and adolescents with diabetes may have abnormalities in immune function resulting in increased morbidity and mortality from infections. Administration of the recommended pneumococcal vaccine and the annual administration of the influenza vaccine prior to flu season can decrease the risk of these diseases and their associated complications.


Gap: Influenza vaccinations are administered annually.

Physicians and staff members are unaware of clinician’s increased responsibility for annual administration of the influenza vaccine to patients with diabetes. Or, they may be unaware of changing recommendations.

• Become familiar with the following guidelines:

The Centers for Disease Control and Prevention (CDC): Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011

The 2012 Child & Adolescent Immunization Schedules for persons aged 0–6 years, 7–18 years, and catch-up schedule

The 2011–2012 AAP policy statement, Recommendations for Prevention and Control of Influenza in Children

The CDC Morbidity and Mortality Weekly Report (MMWR) document for updated guidance for the use of influenza vaccines in the United States for the current influenza season


The AAP policy, Type 2: Clinical Practice Guideline for the Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents. (Check back for link; anticipated release early 2013.)




• Educate staff on the importance of timely influenza vaccines and proper administration:

Keep vaccine administration information by age up-to-date and accessible.

Be aware of true contraindications for administering the vaccine and of recommendations regarding influenza vaccination for persons who report allergy to eggs.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm


http://www.cdc.gov/vaccines/schedules/index.html


http://pediatrics.aappublications.org/content/128/4/813.abstract?sid=16a94c0b-4083-491c-97a4-a0371a3c107b

http://pediatrics.aappublications.org/content/128/4/813.abstract?sid=16a94c0b-4083-491c-97a4-a0371a3c107b









Patients with diabetes in the practice are not easily identified, hindering notification of the need for annual influenza vaccine.

• Develop a registry or paper-based method to identify all patients with diabetes in your practice. For information on establishing a registry to ensure optimal diabetes care, including examples, see the following:

Better Diabetes Care: Framework for Making Systems Changes

EQIPP Medical Home for Pediatric Primary Care course (Registration required)

The AAP/MCHB Building Your Medical Home toolkit, Section 3, Step 2 (Requires log in)

• Use the computerized registry to prospectively identify and track patients with diabetes for annual flu vaccine. The use of paper-based systems such as patient lists, index cards, or color-coded chart stickers can accomplish this task manually.

• Contact patients to schedule vaccinations.

• Assign the responsibility to specific staff members for monitoring whether a flu shot has been administered/offered to all patients with diabetes 6 months of age or older prior to and during the current flu season.

• Include a prompt in your EHR system at the point of care to recommend an annual flu shot and document its administration or refusal of the vaccine.

• Assign a specific staff person to monitor administration or refusal of vaccine to all patients with diabetes aged 6 months or older. Schedule repeated contacts as necessary.

Immunization records are not available for all patients, perhaps because patients recently transferred into the practice or because vaccinations were administered at other sites such as walk-in clinics.

• Request a release of information to obtain immunization and other health data from the patient’s previous physician or care provider.

• Obtain immunization data from the State Department of Health Immunization Program, if registry is available.

• Monitor receipt of information and contact again for information if not obtained within one month.

Responsibility for vaccine monitoring is unclear.

• Within the medical home, establish a clear practice protocol with well-defined roles and responsibilities for vaccine monitoring, administration, documentation, and follow-up prior to and during flu season.

• For patients who are regularly seen by specialists outside of the medical home, establish clear care coordination agreements that delineate the responsibilities for immunization monitoring and administration.

• Review Section 3: Care Delivery Management, of the American Academy of Pediatrics (AAP)/Maternal and Child Health Bureau (MCHB) Building Your Medical Home toolkit, which contains many care coordination tools and resources.

Inadequate insurance coverage or limited financial resources prevent individuals from receiving annual flu immunization.

• Identify community resources for obtaining flu shots at low or no cost such as state, regional, and local health departments or school programs.

• Enroll your practice in the Inspector General’s Vaccines for Children Program, which provides immunizations free of charge for eligible children.

http://betterdiabetescare.nih.gov/FRAMEWORKinformationsystems.htm#starting

http://www.pediatricmedhome.org/



http://www.cdc.gov/vaccines/programs/vfc/default.htm




Practice scheduling and limited access to care may prevent some patients from receiving vaccinations.

• Consider alternative strategies, days, or times to administer influenza vaccinations that improve access to care—for example, scheduling walk-in flu shot clinics, nurse-only visits, or additional evening or Saturday appointments.

• Refer families to community resources that provide flu shots at more accessible times or on walk-in basis.

The patient and family do not recognize the potential severity of influenza and the increased risk for patients with diabetes. The importance of an annual vaccine is unclear to them.

• Prior to the flu season, provide education materials and face-to-face information to patients and families about the importance of an influenza vaccine for all persons aged 6 months and older, especially those with diabetes. Cull information from sources such as the following:

Influenza disease page on the AAP Immunization Web site

AAP resource, Quick Facts: What You Need to Know about Influenza

Printable fact sheet from the CDC, Key Facts About Seasonal Flu Vaccine

10 Reasons to Vaccinate Your Family from Influenza from PreventChildhoodInfluenza.org

Free flu resource materials from the CDC

• Help them to understand the potential severity of influenza and the increased risk from complications. Address any misconceptions.

• Encourage all family members of patients with diabetes to be vaccinated against influenza.

• Consider alternative messaging strategies such as the following:

Include a seasonal poster about flu shot recommendations in the waiting room and examination rooms.

Post information on your practice Web site or include in your practice newsletter.

Send an e-mail blast.

Plan outreach/communication with schools and other community partners.

Gap: Pneumococcal vaccines are not administered annually.

Physicians and staff members are unaware of clinician’s increased responsibility for administering the PCV13 vaccine to patients with diabetes. Or, they may be unaware of changing recommendations.

• Follow the most current age-appropriate schedule available from the CDC for administration of the pneumococcal vaccine. At the time of this course writing, it is the 2012 Child & Adolescent Immunization Schedules for persons aged 0–6 years, 7–18 years, and catch-up schedule available at cdc.gov.

• Consult additional guidelines for more information:

Pneumococcal polysaccharide Vaccine (PPSV) available from www.cdc.gov

Licensure of a 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and Recommendations for Use Among Children – Advisory Committee on Immunization Practices (ACIP), 2010 (Red Book)

• Educate staff on the importance of timely administration of PCV13 vaccine and proper administration.

Keep vaccine administration information by age up-to-date and accessible.

Be aware of contraindications and precautions for administering the vaccine.

http://www2.aap.org/immunization/illnesses/flu/influenza.html

http://www2.aap.org/immunization/illnesses/flu/quickfacts_influenza.pdf

http://www2.aap.org/immunization/illnesses/flu/quickfacts_influenza.pdf

http://www.cdc.gov/flu/protect/keyfacts.htm

http://www.cdc.gov/flu/protect/keyfacts.htm

http://www.preventchildhoodinfluenza.org/documents/10_reasons.pdf

http://www.cdc.gov/flu/freeresources/index.htm




http://www.immunize.org/catg.d/p2015.pdf







AAP; Committee on Infectious Diseases. Policy Statement: Recommendations for the Prevention of Streptococcus pneumoniae Infections in Infants and Children: Use of 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and Pneumococcal Polysaccharide Vaccine (PPSV23) Pediatrics. 2010;126(1):186-190; published ahead of print May 24, 2010, doi:10.1542/peds.2010-1280

Patients with diabetes in the practice are not easily identified, hindering notification of the need for PCV13 vaccine.

• Develop a registry or paper-based method to identify all patients with diabetes in your practice. For information on establishing a registry to ensure optimal diabetes care, including examples, see the following:

Better Diabetes Care: Framework for Making Systems Changes

EQIPP Medical Home for Pediatric Primary Care course (Registration required)

The AAP/MCHB Building Your Medical Home toolkit, Section 3, Step 2 (Please sign in to view the toolkit; free to AAP members.)

• Use the computerized registry to prospectively identify and track patients with diabetes for PCV13 administration. The use of paper-based systems such as patient lists, index cards, or color-coded chart stickers can accomplish this task manually.

• Contact patients to schedule vaccinations.

• Assign the responsibility to specific staff members for monitoring whether a PCV13 shot has been administered/offered to all patients with diabetes aged 2 months or more.

• Include a prompt in your EHR system at the point of care to recommend review of PCV13 immunization status.

• Assign a specific staff person to monitor administration or refusal of vaccine to all patients with diabetes. Schedule repeated contacts as necessary.

Immunization records are not available for all patients, perhaps because patients recently transferred into the practice or because vaccinations were administered at other sites such as walk-in clinics.

• Request a release of information to obtain immunization and other health data from the patient’s previous physician or care provider.

• Obtain immunization data from the State Department of Health Immunization Program, if registry is available.

• Monitor receipt of information and contact again for information if not obtained within one month.

Responsibility for vaccine monitoring is unclear.

• Within the medical home, establish a clear practice protocol with well-defined roles and responsibilities for vaccine monitoring, administration, and documentation of PCV13.

• For patients who are regularly seen by specialists outside of the medical home, establish clear care coordination agreements that delineate the

• Review Section 3: Care Delivery Management, of the American Academy of Pediatrics (AAP)/Maternal and Child Health Bureau (MCHB) Building Your Medical Home toolkit, which contains many care





http://betterdiabetescare.nih.gov/FRAMEWORKinformationsystems.htm#starting






Potential Barriers Suggested Ideas for Change Still Not Seeing Results? responsibilities for immunization monitoring and administration. coordination tools and resources.

Inadequate insurance coverage or limited financial resources prevent individuals from receiving PCV13 vaccine.

• Identify community resources for obtaining PCV13 vaccine at low or no cost such as state, regional, and local health departments or school programs.

• Enroll your practice in the Vaccines for Children Program, which provides immunizations free of charge to eligible children.

Practice scheduling and limited access to care may prevent some patients from receiving vaccinations.

• Consider alternative strategies, days or times to administer PCV13 vaccinations that improve access to care—for example, scheduling walk-in clinics, nurse-only visits, or additional evening or Saturday appointments.

• Refer families to community resources that provide PVC13 vaccines at more accessible times or on walk-in basis.

The patient and family do not recognize the potential morbidity and mortality of pneumococcal disease and the increased risk for patients with diabetes. The importance of the PCV13 vaccine is unclear to them.

• Provide education materials and face-to-face information to patients and families about the importance of a PCV13 vaccine for all persons aged 2 months and older, especially those with diabetes. Cull information from sources such as the following:

Pneumococcal disease page on the AAP Immunization Web site

Printable fact sheet from the CDC, Key Facts About PCV13

Diabetes and Pneumonia: Get the Facts, a resource for families from the CDC

Pneumococcal polysaccharide vaccine (PPSV) CDC answers your questions

• Help families to understand the potential severity of pneumococcal disease and the increased risk from complications. Address any misconceptions.

• Consider alternative messaging strategies such as the following:

Include a poster about PCV13 recommendations in the waiting room and examination rooms.

Post information on your practice Web site or include in your practice newsletter.

Send an e-mail blast.

Plan outreach/communication with schools and other community partners.

http://www.cdc.gov/vaccines/programs/vfc/index.html

http://www.cdc.gov/vaccines/programs/vfc/index.html

http://www2.aap.org/immunization/illnesses/pneumococcal/pneumococcal.html

http://www.cdc.gov/vaccines/vpd-vac/pneumo/default.htm

http://www.cdc.gov/diabetes/projects/pdfs/eng_facts.pdf



Documents

Potential Barriers and Suggested Ideas for Changeeqipp.aap.org/File Library/Courses/Diabetes/Tools...Potential Barriers Suggested Ideas for Change ... (ISPAD) Clinical Practice Consensus