• Fresh Views

    Telehealth: A solution-focused practice

    Lorena Drago, MS, RDN, CDN, CDCES

    As telehealth continues to be a key aspect of healthcare, we reached out to our friend and fellow diabetes care and education specialist Lorena Drago MS, RDN, CDN, CDCES, owner of Hispanic Foodways LLC, to share her experience and solution-focused approach to engaging in successful telehealth visits.

    Here is what Lorena shared with us….

    Many health professionals have now adopted telehealth visits as part of diabetes care and education. I must admit that it has been a bumpy ride for health care providers and patients. Many of us have experienced technical issues. We are familiar with the “Can you hear me now?” plight as we connect to audio or have fallen victim to nostril intimacy when the patient moves the camera too close to the face. Let’s not mention those patients who believe pants are optional.

    Overall, there are many advantages to telehealth, such as convenience, saving time, and saving money on travel. Despite working out some kinks, there are still some challenges, such as lack of internet, poor connectivity, and low digital health literacy.

    After a year and a half of telehealth visits, I would like to share my solution-focused practice approach to optimizing virtual visits.

    BEFORE THE VISIT: PREPARATION IS KEY

    FOR THE PATIENT

    Create a checklist and review with patient prior to the appointment.

    • Does the patient have access to a computer, laptop, tablet, or phone?
    • Does the patient have internet access? 
    • Have they downloaded the application they will use for the telehealth appointment? Do they need help? Do they know how to use it?
    • Do they have a quiet designated space for the telehealth appointment?
    • Has the patient completed labs, if required?
    • Does the patient have his/her anthropometric measurements?
    • Does the patient have his/her blood glucose results available?
      • Is the patient able to upload his/her results into the hospital/clinic portal?
      • Is the patient’s meter, CGM, smart insulin pens, and pump connected to a platform where the health care team can access the information?
    • Have they completed the required patient forms prior to the appointment? 
    • Do they have insurance information?
    • If it is a nutrition appointment, do they have foods and labels they would like to discuss?

    A patient navigator or administrative staff can compile this information and help prepare the patient for the visit. For patients who experience some of the aforementioned challenges, a telephone visit may be preferable.

    FOR THE DIABETES CARE AND EDUCATION SPECIALIST

    Prepare the agenda for the visit.

    What does the patient want to know? I ask the patient:

    • What are 1-2 questions you would like answered before the end of this appointment?
    • What would you like to learn today?
    • What is going well with your diabetes management?

    Build on what the patient already knows.

    If you can share the screen, show the patient a list of foods. Ask, “which of these foods raise your blood glucose the most? If you are not sure, just tell me you are not sure.” After the individual selects the foods, I know what the knowledge gaps are, and I shift the education to bridging the gaps in knowledge.  For example, I provide a handout with pictures of whole wheat bread, skim milk, whole milk, fish, carrots, nuts. If the patient says that whole milk raises blood sugar and skim milk does not, then I focus on discussing the difference between carbohydrates and fat.

    Focus on the wins.

    When you discuss glucose management, it is common to focus on out-of-range results. After all, it is paramount to identify and manage hypoglycemic events. However, there is an inherent fear that the healthcare provider will admonish the patient for poor results. To avoid this, I ask:

    What do you think happened?

    This question invites exploration and reflection. Allow the patient to pause and reflect. Usually, patients will say, “I forgot to eat, or I did not eat enough carbohydrates.” Ask,

    What have you done in the past that has worked for you to remind you to do something?

    This question will allow the patient to recall past effective strategies and positive outcomes.  If the patient doesn’t come up with any answers, then offer suggestions that have worked for other patients.

    Make sure to use teach-back. Ask: 

    Can you tell me or show me in your own words.  Can you summarize the key points of today’s visit?

    Goal setting

    Establishing goals is often tricky for some patients. I usually create a list of goals and ask the patient to select an easy win. This way, it is easy to achieve, and the patient will be more likely to move forward. For those patients who are goal driven, formulate more complex goals and adapt to the patient.

    AFTER THE VISIT: DATA REVIEW IS REIMBURSABLE

    CPT Code & Service Provided

    • 95249: Patient equipment, CGM placement, hook-up, calibration, training, sensor removal, and printout recording.
    • Service performed by: MD, NP, PA, RN, PharmD, RDN, CDCES
    • Reimbursement: Medicare: ~$55, Commercial ~$127

    95251: CGM data interpretation

    • Service performed by: MD, NP, PA
    • Reimbursement: Medicare ~$40, Commercial: ~$100

    99457, 99091: Remote patient monitoring; collection and interpretation of physiologic data

    • Service performed by: MD or other qualified health professional
    • Reimbursement: Medicare: ~$50-$60

    Lorena created the Diabetes Teaching Tools for your Virtual Practice to help diabetes educators:

    • Reduce consultation time
    • In less than 3 minutes, identify what the client doesn’t know so you can focus on what the client needs to know.
    • Engage the client in the learning process using “real-life examples.”

    The diabetes teaching tool kit includes:

    • 13 topics presented in a simplified-visually rich style
    • 8 interactive activities with real-life examples to help patients use newly acquired information
    • Tried and true carbohydrate knowledge assessment tool so you know what your patients know and don’t know about foods with carbohydrate
    • Download and share with your patients: https://rd2rd.com/downloads/diabetes-teaching-tools-for-your-virtual-practice/ 

    We thank Lorena for the multitude of solution-focused practice pearls she shared with us and our readers in this week’s blog!

    Stop back by in 2 weeks to see what we write about as we continue to share about a variety of other technologies that impact and influence diabetes care and education!

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown DIabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Diabetes Technology and Solution-Focused Practice: A Telehealth Experience

     It’s not what you look at that matters; it’s what you see. – Henry David Thoreau

    Joshua Tree National Park, California

    Back in January we shared the top 10 things that 2020 taught us (you can read it here) and #5 was to Keep a mindset focused on finding solutions, rather than focusing on problems. Little did we know that we would be applying that lesson to many aspects of our lives throughout the year. In some ways it’s difficult to believe that an entire year has passed since the world first shut down and the new concept of “social distancing” became the norm. And with that the need to quickly find a solution to no longer being able to meet with clients in person. Tami works with a dually accredited Diabetes Self-Management Education and Support program (DSMES) in public health which quickly became part of a statewide pilot to pivot to online virtual delivery. Rather than fixating on the “problem” at hand (no longer being able to meet in person), she and the team focused on creating solutions, leveraging the ideas, input, skills and expertise of the team she works with. To echo the Thoreau quote above, it’s all about what you envision and see in looking to the future.

    Here’s Tami’s telehealth experience…

    I will never forget hearing people say, “What’s so hard about switching to facilitating online. You just open up your computer and talk!” But it quickly became evident that virtual delivery is SO much more than that…my home office rapidly transformed into a small studio complete with green screen for virtual background (to hide the chaos of working from home), a webcam (for clear image and sound), a ring light (for proper lighting), a second device to log-in (to see what the participants are seeing), elevating my laptop (so it was the right height), rigging up my desk so all props were within reach, placing my notes where I could see them and still look in the camera, plus learning how to use Zoom and Docusign!  And not to mention adapting the entire curriculum and mode of delivery to be interactive and engaging. Many times I told my husband I not only had to be a content expert, but also be engaging, be entertaining, and be my own IT. It seemed that each day new considerations and challenges popped up (after all, I didn’t know what I didn’t know), but we kept a mindset focused on building solutions. And thank goodness for technology in these days of “social distancing”! The photo above from Joshua Tree is reflective of the many pieces and aspects that together built a successful telehealth program and required us to rely on a strong network of people, technology and new ideas to be resilient. (If you’ve followed our blog, you know we enjoy sharing a fresh view through an inspiring photo with each post!)

    Tami’s office set-up for virtual delivery

    Engaging differently through virtual visits

    One quick learning with the transition to virtual DSMES delivery was that engagement is significantly different through virtual visits. Engaging virtually can bring an added level of stress…How do I connect to Zoom? My internet is unstable. How do I mute myself? Can you hear me? How do I turn off my camera? Can you see me? How do I position my laptop because I don’t like what’s in my background or how I look?…I bet you can relate to some of these! In an effort to reduce stress, and start each encounter on a positive note, I started each session in a solution-focused manner with the questions: What’s 1 thing that went well this past week (no matter how big or small)? What’s 1 change you were able to make? How were you able to do that?  Whether unmuting and sharing, or replying in the chat, this helped acknowledge each individual’s hard work and guide the discussion toward finding solutions. At the conclusion of each DSMES series when setting post-program goals, again we turned focus to areas each individual was already achieving some success and how they could leverage that for future benefit.

    Telehealth virtual delivery was a success!

    I’m happy to share that after facilitating multiple cohorts our program has had a 100% completion rate for most of the cohorts! Much higher engagement and completion than in-person delivery. That’s a huge win!

    How has technology changed your practice or your thinking? We’d love to hear from you!

     Over the next few posts we’ll write about a variety of other technologies that impact and influence diabetes care and education including diabetes apps, digital health tools, diabetes devices, online peer support and online coaching. Stop back by in 2 weeks to see what’s up next!

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!


    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients.

    Deb is employed by Dexcom but her words and opinions in this blog are her own.

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