(Management Case Study) Implementation of a New Interdisciplinary Practice Model Utilizing Continuous Glucose Monitoring and Low Carbohydrate Counseling to Improve Wellness Among Veterans With Diabetes

Purpose: The VA healthcare system incorporates clinical pharmacists and registered dietitians within the primary care practice model to work with Veterans in planning life-long wellness. For patients with diabetes, growing evidence demonstrates that health targets are achievable through adherence to a carbohydrate restricted lifestyle. While potentially effective, such changes require intensive instruction and close monitoring to mitigate the risk of hypoglycemia. This case describes feasibility and efficacy of a new interdisciplinary practice model within a VA healthcare system utilizing intensive glucose monitoring to personalize counseling focused on carbohydrate restriction, medication optimization and avoidance of weight related health complications.

Methods: An interdisciplinary team consisting of physician(s), registered dietitian(s) and a clinical pharmacist practitioner with experience in low carbohydrate counseling, interpretation of continuous glucose monitoring and management of complicated diabetes regimens proposed a quality improvement initiative for a new interdisciplinary practice model within primary care a VA healthcare system. Veterans with type 2 diabetes on basal plus bolus or u500 insulin, who met criteria for continuous glucose monitoring, completed the (established) virtual education class and expressed an interest in deescalating pharmacotherapy through adherence to a carbohydrate restricted lifestyle were invited to participate. Interventions were delivered virtually by the afore mentioned primary care team members in regular intervals over twenty four weeks. Both the registered dietitian and clinical pharmacist practitioner accessed continuous glucose monitoring data using a web based platform. The registered dietitian provided personalized education and guidance to help participants achieve a lower carbohydrate meal plan. The clinical pharmacist practitioner ensured timely follow up and adjustments to patients’ medication regimen. The clinical pharmacist practitioner additionally reviewed these data at weekly intervals and initiated an unscheduled visit for medication change and coordinated care as needed. Furthermore, the physician(s), registered dietitian(s) and clinical pharmacist practitioner, completed collaborative monthly meetings to evaluate changes in medication use, weight, laboratory outcomes and overall program acceptability and feasibility.

Results: An estimated 0.1 full time equivalent of an established primary care clinical pharmacist practitioner and 0.15 full time equivalent for established registered dietitians was allotted for this quality improvement initiative. The physician(s) dedicated approximately 20 minutes for initial veteran communications, time for ordering and reviewing laboratory test and monthly meetings. Patient participation was limited to 10 veterans on a rolling basis to facilitate intensive patient care but allow for additional patients access. Veterans responded favorably to completing virtual encounters with frequent occurrences over 24 weeks. Use of a web based platform was deemed successful and convenient for evaluating continuous glucose monitoring, as an educational tool and for initiating interventions. Seventy percent of enrollees completed 24 weeks of collaborative care. Primary care teams readily accepted notification of patient participation and often documented satisfaction with outcomes. Additionally, this practice model was accepted as an equivalent to other specialty comprehensive weight loss programs offered at our facilities.
Regarding efficacy, there was an overall mean decrease in weight of 14.7 kilograms, HbA1c of 1.1, triglycerides of 98.2, and LDL of 2.6 with a mean increase in HDL of 3.8. Among completers, 94 percent discontinued bolus insulin and 76 percent discontinued basal insulin.

Conclusion: This case supports the feasibility of incorporating a new interdisciplinary practice model within a VA healthcare system. Collaboration between registered dietitian, clinical pharmacist practitioner and physicians to intensively counsel on carbohydrate restrictions through close monitoring utilizing continuous glucose monitoring via a web based platform was achievable without subsequent need for additional staff. Furthermore, this practice model was well received by both veterans and providers with results demonstrating favorable outcomes in health targets and medication optimization. Ultimately, this design and partnership aligns with the VA primary care practice model in planning life-long wellness and avoidance of health complications for veterans.