“A multidisciplinary team approach is critical to success in diabetes care and complications prevention,” according to the CDC. When key health messages are delivered by all providers, they can help diabetic patients reduce the risk of blindness, tooth loss, amputations and heart disease, among other serious complications.¹

As part of this collaborative approach, the optometrist’s role in caring for diabetic patients can be significant due to the vision-related issues associated with the disease, including fluctuating and blurred vision, dry eye disease or worse, diabetic eye disease. Because of these issues, the optometrist is often the first to identify the symptoms or ocular complications of the disease.

In addition, in managing the ocular issues related to diabetes, optometrists tend to be the doctors who see diabetic patients most often, aside from the endocrinologist or primary care physician. This places the optometrist in an excellent position to help provide exceptional care by creating referrals and building relationships with the other health care providers the patient sees.

Here, I explain how to easily and efficiently build collaborative care relationships with health care professionals, and I discuss these other team members.

BUILDING COLLABORATIVE RELATIONSHIPS

Consider these tips to develop relationships with the other providers of diabetic care on the health care team:

• Make an office visit. The best way to establish relationships with health care practitioners is to visit their offices. Shaking hands, making eye contact and having a conversation about a shared commitment to a patient’s health goes a long way. This personal contact will also cause them to think of the O.D. first when they refer their patients for eye examinations. Personally, I carve time out of my schedule to make these visits during slower times of the year and visit all the practitioners within a five-mile radius.
• Use staff. At our office, we are fortunate to have an amazing marketing support staff. They are our representatives who visit other health care providers’ offices, obtain necessary information, such as fax numbers, and keep the lines of communication open. They act as an intermediary between our office and the other health care providers to easily relay messages. If able, I would highly recommend other optometrists have a similar staff in place.
• Report pertinent medical information. In our office, for example, we are fortunate to have an EHR system that makes this simple: On completion of the patient’s chart note, a communication letter can be generated with two clicks and faxed directly to the intended doctor. This quick and efficient mode of communication instills confidence in our collaborative team of practitioners and makes them want to work with us more, thus, building our reputation in the medical community and growing our practices by referrals.
• Ask permission to contact providers. Keep in mind patients may already have established providers, in which case, O.D.s should ask patient permission to reach out to the other health care providers and the providers’ contact information. This way, optometrists are able to both provide and receive recent health information from the said providers. Then, during follow-up examinations, O.D.s should ask patients how their visits with their other providers went and whether they have any concerns. This allows us to make sure the patient is following our directions and alleviates any miscommunication that may occur.

HEALTH CARE TEAM MEMBERS

The health care team members for the diabetic patient may include:

Projections for Diabetic Retinopathy in 2010-2030-2050 (in millions)

 

 

• PCPs. Optometrists should be aware of and refer patients (when necessary) to well-established PCPs in the community who can prescribe aggressive therapy, as these patients can have an emergent need. The goal for a diabetic patient is to have a daily hemoglobin A1C, or estimated average glucose, reading of below 7%, or 154 mg/dL.² We need to remind our patients of these numbers and emphasize the importance of maintaining these levels to prevent the ocular complications of diabetes.
• Endocrinologists. Most Type 1 diabetes patients, and many Type 2 diabetes patients, see an endocrinologist to help them get their disease under control. A referral to an endocrinologist is necessary when these patients have poor blood sugar control, show signs of complications, such as diabetic retinopathy or when they have co-morbidities of the endocrine system, such as hyperthyroidism, osteoporosis or thyroid cysts.
  Maintaining good communication with these providers is key. For example, reporting the presence of retinopathy, however mild, tells the endocrinologist that the disease has advanced and tighter blood sugar control is necessary. These conversations also help us in knowing how compliant our patients are with their endocrinology follow-up appointments.
• Ophthalmologists. Our friends who are ophthalmologists, especially retinal specialists, are a critical part of the diabetic patient’s health care team. I have personal friendships with a couple retina specialists locally. Having these relationships makes it easy to text or to call and ask a question or seek advice, not to mention, getting the patient seen as soon as possible, if necessary. This is a two-way street as well: I have had the same ophthalmologists text me and ask me to see a patient who has a high IOP.
  When we examine a patient who has diabetic retinopathy, it is extremely important to properly evaluate the level of pathology. When the patient shows signs of severe retinopathy or any signs of clinically significant macular edema (CSME), we must refer him to a retinal specialist as soon as possible, as the patient may require prompt treatment.
• Dieticians. Although most PCPs or endocrinologists either employ certified dieticians or refer diabetic patients to them after the initial diagnosis, some patients do not follow through with this specialist. This may be, in part, because they did not receive enough education on the importance of diet in controlling their disease.
  As a result, I suggest O.D.s ask their diabetic patients whether they have seen a certified dietician who has designed a beneficial meal plan. (The best type of diet for a diabetic patient is one designed with five meals per day, high protein, low carbohydrates and low fat, with very small portion sizes.)² If the patient has not yet seen a dietician, optometrists should provide him with names of pre-vetted dieticians. The patient’s endocrinologist is a good source for these professionals. The dietician should be experienced in advising and treating diabetic patients.
• Behavioral professionals. It is quite common for newly diagnosed diabetic patients to suffer as a result of a diagnosis. To determine whether these patients have been feeling sad, guilty, hopeless and/or worthless, among other symptoms, optometrists should consider employing a questionnaire (see “Depression Screening Text,” bit.ly/19FdcTR ). If the patient’s score reveals depression, optometrists should refer him to a psychiatrist and/or psychologist. I recommend referring the patient to someone who is experienced and specializes in the area of depression and other emotional changes.
• Cardiologists. O.D.s should ask all diabetic patients whether they’ve seen a cardiologist for a complete workup, as the disease is known to increase a person’s risk of heart disease and stroke. If the patient has not, the optometrist should briefly educate him on the importance of seeing a cardiologist and refer the patient to one. In cases of co-morbid microvascular changes, such as Hollenhorst plaques, or in cases in which there is a history of transient visual obscurations, optometrists should contact the cardiologist directly and emphasize the emergent need for evaluation.
• Dentists. Increased inflammation, infections, bleeding while brushing or flossing and xerostomia (dry mouth, due to lack of saliva flow) are quite common in diabetic patients. As such, O.D.s should ask diabetic patients the last time they’ve seen their dentist and inform them that studies suggest regular cleaning and treatment of periodontal disease can lower A1C levels in diabetic patients by at least 0.4%.³ Optometrists should refer patients to a dentist, as needed.
• Podiatrists. If a patient presents with peripheral paresthesia or microvascular changes, such as micro aneurysms, intra-retinal hemorrhages, cotton wool spots, etc., noted on dilated examination, It is likely that similar changes are present in the peripheral capillary tissues of the feet.

In fact, roughly 60% of all non-traumatic lower-limb amputations among people age 20 or older occur in people who have diabetes.⁴ Diabetes damages the nerves, and paresthesia can be one of the first signs of neuropathy. As a result, O.D.s should refer patients to podiatrists who specialize in wound care and paresthetic complications of microvascular disease.

NURTURE RELATIONSHIPS

The most effective way to prevent complications from diabetes is to manage the disease aggressively and early by utilizing a team approach. We can play an important role in collaborating with other healthcare professionals to prevent these patients from suffering complications. By doing so, our diabetic patients have an excellent chance of maintaining their ocular and systemic health, they become loyal to us, and we receive referrals from other team members who value our skillset. Everyone wins. OM

REFERENCES

1. Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry and Dentistry. Centers for Disease Control Website. https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide.pdf . Accessed March 9.
2. A1C does it all. American Diabetes Association website. https://www.diabetes.org/a1c . Accessed March 9.
3. Borgnakke WS, Ylöstalo PV, Taylor GW, Genco RJ. Effect of periodontal disease on diabetes: systematic review of epidemiologic observational evidence. J Clin Periodontol 2013; 40(suppl 14): 135-152.
4. Hoffstad, O., Mitra, N., Walsh, J., Margolis, D. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care. 2015, 38(10): 1852-1857

DR. FICCO practices with O.D.s and M.D.s at Milan Eye Center in Cumming, Ga. He serves as externship coordinator. He lectures nationally on ocular disease and has written several articles on eye care. Email him at cficco@milaneyecenter.com.