COMPREHENSIVE DIABETES GROUP CLINIC
The CDGC care team includes the attending physician, resident physician, clinical pharmacist, medical assistant, and dietician. Periodically a medical and/or pharmacy student is also involved in history taking during patients visit. The role of each team member is described below.
Clinics are scheduled for every Friday morning. Patients are discharged from CDGC solely to follow-up with their PCPs after three visits and individualized Hb A1C goal is achieved.
o Physician and Clinical Pharmacist: The pharmacist conducts a medication reconciliation and initial patient interview prior to the medical resident seeing the patient. The patient interview focuses on obtaining accurate medication history, identifying any diabetes medication related issues including hypoglycemic episodes, recording SMBG from patient’s monitor, and assessing appropriate administration of medications. After the initial interview, the pharmacist discusses findings and therapeutic recommendations with the medical resident. The pharmacist also verifies insurance formulary criteria for any new medications prescribed at the visit to resolve coverage issues.
The physician then additionally interviews the patient, with the intent of re-affirming discussions had by pharmacist. More discussion is had in regards to lifestyle modifications, appropriate medications and importance of compliance with treatment plan. Patient’s health literacy of condition is also discussed.
Collaboratively, a plan is generated for the patient which includes setting an individualized A1c goal, pharmacotherapy adjustments, and monitoring plan. Complex patient cases or therapeutic questions are presented to the attending physician before the plan is finalized for the patient.
o Dietitian: Provides individual sessions to discuss appropriate food choices and the effects on diabetes management.
Registered Dietitians, Certified diabetic educators and RNs,
Content: A1C, hyperglycemia, and hypoglycemia and when and how often to check these parameters
Carb counting, calorie counting, proper meal selection, and demonstration of diabetic diet plate and snacks
Patients are encouraged to return for support if needed
o Medical assistants (MA): MAs room the patient and record vitals at the beginning of the visit. They also pre-filled an intake sheet with the date of the patient’s last foot exam, retinal exam, and urine albumin, providing that to the pharmacist and physician before they entered the room. During the visit, the MA performed foot exam if due and performed point of care (POC) A1c checks when ordered by the physician. At the end of the visit, they provided the visit summary and scheduled the patient’s next visit in the system.
o Nurses: Nurses are available for teaching the appropriate application of prescribed medications, especially insulin. Materials are brought into the room and patients have the ability to practice with the injections. Nurses are also available for teaching and education.