Hellping Yourself With Diabetes

[Guest guest]

GREETINGS --

The following article from the diabetesselfmanagement website, though

lengthy, provides many suggestions to help us better deal with our

diabetes challenges.

wambo

As everyone with diabetes knows, much of the responsibility for

diabetes care falls on the shoulders of the person who has it. You

are in charge of monitoring your blood glucose every day, taking your

insulin or oral drugs, choosing foods that fit your meal plan, and

working exercise into your schedule. But even if you provide the bulk

of your diabetes care, that doesn't mean you should have to manage

your diabetes all alone. In fact, you really can't, which is why you

should have a diabetes-care team.

Your diabetes-care team members are experts in different areas of

diabetes management. Most teams have as a core group a doctor, a

diabetes nurse educator, and a dietitian. Some other members you may

have on your team include a mental health professional,

ophthalmologist or optometrist, foot-care specialist, pharmacist, and

exercise physiologist or physical therapist. Some people may also

have a neurologist, kidney specialist, or any number of other medical

specialists on the team. The list of team members can go on and on.

The point, however, is that you are likely to have many people

involved in your diabetes care. In general, that's a good thing. But

it can be a challenge to get all your diabetes-care team members to

work together to achieve the best results.

In an ideal world, all the members of your diabetes team would

communicate with one another to coordinate your care and make sure

that you get all the tests, checkups, education, and treatments that

you need. If you needed to see a specialist not currently on your

team, your primary-care doctor would give you a referral, and your

insurance company would cover the specialist services.

In a more realistic world, your doctor may not practice in a diabetes-

care center that supports a team system. Your various health-care

providers may not communicate with each other. Your insurance company

may not see the necessity of paying for visits to an exercise

specialist or mental health professional. And you may find you have

to remind your primary-care provider to write you a referral to an

eye doctor once a year or to examine your feet at every regular

diabetes office visit.

In this more realistic world, you may have to be in charge of

coordinating your care. That means you not only have to manage your

diabetes on a day-to-day basis, but you also have to ensure that your

medical and educational needs are being met. Some people call this

being a self-advocate.

The skills of self-advocacy seem to come naturally to some people.

Many others, however, have to learn them. The good news is that the

skills of self-advocacy can be learned, and it doesn't require a

personality overhaul or assertiveness-training courses.

One of the most important parts of self-advocacy is knowledge—of the

latest guidelines for diabetes care, of what your health insurance

plan covers, and of new diabetes treatments. Another part is becoming

an expert on you and your diabetes by keeping records of your blood

glucose levels and self-management routines. And another part is

speaking up, including letting your health-care providers know what's

working and what's not.

Changing world, changing needs

Self-advocacy has always been important, but today it is perhaps more

necessary than ever for two reasons: recent changes in the health-

care system and the ever-increasing number of options for the

treatment of diabetes.

In the past decade or so, the health-care system in the United States

has changed phenomenally as insurance companies and the U.S. and

state governments have tried to rein in health-care spending. Fee-for-

service plans are rapidly being replaced with health maintenance

organizations, preferred provider organizations, and other managed-

care plans. In the old system, health-care consumers often had

minimal responsibility for the course of their treatment. In the new

system, it helps a lot to know what resources are available to you

and how to access them.

New treatment options for people with diabetes include new drugs, new

insulins, and new methods of insulin delivery. Guidelines for diet

and exercise have evolved, too, in recent years. These developments

bode well for improved blood glucose control, but they can also mean

that new information must be learned and new skills acquired. Making

sure you get the information, education, and skills training you need

to take advantage of new treatment options may require using many of

the skills of self-advocacy.

Start with knowledge

As a participant in your treatment plan, it's helpful to learn as

much as possible about prudent diabetes care and your own treatment

options. To get a general sense of what your medical care should

include, take a look at the guidelines developed by the American

Diabetes Association (ADA) to maintain optimal health and help

prevent complications.

The ADA recommends that all people with diabetes have their weight,

blood pressure, and feet checked at each scheduled diabetes-care

visit. Are you getting these basic exams? An easy way to remind your

health-care provider to check your feet is to take off your shoes and

socks as soon as you go into the exam room.

The ADA also recommends a glycosylated hemoglobin (HbA1c) test

approximately every three months. The HbA1c test gives an indication

of your average level of blood glucose control over the preceding two

to three months. It is a useful tool for determining whether your

diabetes-care plan is doing the job or needs adjustments.

A lipid profile, including total cholesterol level, LDL cholesterol

level, HDL cholesterol level, and triglycerides, is recommended

annually to assess your risk for heart disease and need for

treatment. Some other tests that are recommended on an annual basis

are a dilated eye exam, dental exam, and a test for microalbuminuria,

an early sign of kidney damage. The ADA also recommends getting a flu

shot every year to prevent the flu and its complications.

The ADA guidelines are general guidelines and may be modified by your

health-care team. Specific recommendations for medicines, meal

planning, exercise, and blood glucose monitoring should be tailored

to you, as well.

Know your treatment options

Becoming familiar with available medicines will help you and your

doctor choose what is best for you. For people with Type 2 diabetes,

there are now drugs that increase insulin secretion, including

sulfonylureas (chlorpropamide, glimepiride, glipizide, glyburide,

tolazamide, and tolbutamide) as well as nateglinide and repaglinide;

drugs that decrease absorption of glucose in the digestive tract

(acarbose and miglitol); a drug that decreases the release of glucose

by the liver (metformin); and drugs that help reverse insulin

resistance (pioglitazone and rosiglitazone). All of these may be

prescribed alone or in combination with certain other drugs.

For people who require insulin, there are also choices, including

long-acting insulin, intermediate-acting insulin, short-acting

insulin, and rapid-acting insulin. There is also the choice between

animal-derived insulin, genetically engineered human insulin, and

insulin analogs, which are similar to but slightly different from

human insulin.

How do you know what's new on the market and what might work for you?

Read books, journals, and newsletters. Visit reliable Web sites, and

make a list of online resources that you visit regularly. Attend

diabetes classes and seminars, watch for engagements with speakers

you can learn from, join a support group, and develop the art of

networking in the diabetes community.

Before you ask your doctor for the latest product, think about

whether and why you need a change. Some questions to ask yourself

include the following:

• Am I achieving target ranges for my blood sugar with my current

drug or insulin regimen?

• Is my HbA1c test result below 7%, the goal set out by the ADA?

• Am I able to take my pills or insulin at the times suggested?

• Have I experienced any side effects with my current regimen?

• Will the new pill or insulin I'm interested in taking be safe for

me? (This may depend on whether you have other medical conditions

such as kidney or liver disease.)

• Will a new pill or insulin have any particular benefit over what

I'm using now?

Meal-planning and exercise are equally important parts of managing

diabetes, and there are many approaches to both. If you do not yet

have an individualized meal plan or are having trouble with the one

you have, request an appointment with a dietitian. Speak to your

doctor about safe forms of exercise for you. Choose a program that

you can commit to with consistency and that takes into consideration

your lifestyle and personal likes and dislikes.

Blood glucose monitoring is recommended for everyone who has

diabetes, but the frequency with which you monitor may depend on how

you treat your diabetes and other factors. If you are newly diagnosed

with diabetes, your blood sugar is unstable, or you use insulin, you

will probably want to check more often. In general, you want to check

often enough to get the information you need to make daily diabetes

self-management decisions. Your health-care team can help you choose

a meter, determine how often to use it each day, and determine the

best times of day to check your blood glucose.

Your daily diabetes management routine—including taking medicines,

planning meals, exercising, and checking blood glucose levels—can

only be effective if you follow it consistently. Don't wait to

become " motivated. " Motivation comes from the self-confidence you

gain and the payoff you reap when you initiate action. If something

in your plan doesn't seem to be working, contact your health-care

provider to discuss possible alternatives.

Know your insurance coverage

The documents provided by insurance companies will never be mistaken

for great literature, but it's worth making the effort to slog

through them anyway. Whether you have a choice of policy or not, it's

important to know what's covered and what's not. For example, what is

the prescription coverage? Are most of your prescription needs on the

drug formulary, and if not, what are the costs of nonformulary items?

Will you need a doctor's letter of necessity to help you obtain them?

Are there limits on diabetes supplies? What is the copayment for

doctor visits? Will you be able to see your doctor when you want to?

What is the procedure for being referred to a specialist?

Some other questions to investigate include these: What are the

limits on emergency room or hospital visits? What if you have a

medical problem when you are away from home? What procedures require

preauthorization? What is the appeals process for denied claims? (All

insurance companies have one.)

If you are confused by what you read, call the insurance company's

customer service number with questions. You might also seek help from

someone in your company's human resources department if you get your

health insurance coverage through your job.

Once you have insurance coverage, keep in mind that your insurance

company's policies are subject to change, so if you're scheduled for

an expensive procedure, it doesn't hurt to check and double-check

what's covered. When had her first vitrectomy, she didn't

need preauthorization from the insurance company before the

procedure. So when she was scheduled for a second vitrectomy, she

didn't think she'd need preauthorization for it, either. But she

asked the office manager of her retinal specialist to call and

confirm coverage anyway. As it turned out, a requirement for

preauthorization had been implemented the month before. If

had not checked, she could have been responsible for a substantial

bill.

If you receive a bill or a reimbursement check that doesn't seem

right, call your insurance company immediately. Don't let it sit

around and gather dust. And don't hesitate to use the appeals process

for denied claims when you disagree with a decision. If you call the

insurance company but seem to be getting nowhere, ask to speak to a

supervisor. Document all calls with the date, time, person you spoke

to, and the matter discussed.

learned all of these lessons and more when a human error put

his insurance coverage in jeopardy. had a work-related

disability and wanted to make sure his insurance continued until he

got back to work. He talked to his employer, the disability case

worker, the workman's compensation case coordinator, and an insurance

company representative to confirm continued coverage. Everything was

set, or so he thought until he started receiving medical bills. He

repeated his calls, but no one could tell him what had happened, and

no one had the authority to reinstate coverage.

kept calling until finally an insurance representative checked

her computer records carefully. She saw that a wrong code had been

entered but said the only person who could change it was the person

who had typed it in, and she didn't know who that was.

explained the gravity of his situation forcefully, but politely. She

asked him to hold for a minute, then came back to report the code had

been corrected, and coverage was intact. Sometimes, persistence is

the key.

Become an expert on you

A good self-advocate must also be a good historian and record-keeper.

You and your diabetes team cannot design a plan specifically for you

if there is not enough information on which to base decisions.

An important but oft-neglected record is a personal list of

medicines, doses, and times taken. Keep your list up to date, and

keep it in a place such as your wallet, where it is readily available

for appointments with members of your health-care team. It is also

wise to make a copy for a close friend or family member in the event

of an emergency.

Your list of medicines will come in handy should you have to fill out

a medical history questionnaire. There are some other details you'll

want to have written down, too, such as the date of your most recent

chest x-ray, the dates of any surgeries, highlights of your and your

family's medical history, insurance information, and the names and

addresses of members of your diabetes team and other health-care

providers. The more complicated your medical history, the more

difficult it is to remember things.

Blood glucose self-monitoring records are essential to assess how

your treatment plan is working. Logbooks, meter memory, and

downloading programs are all designed to make this easier. Be sure to

take your blood glucose monitoring records with you to all your

appointments.

Wearing a medical ID is also a form of self-advocacy. In an

emergency, you might be misdiagnosed or given inappropriate care if

vital information about you is not available. A medical ID is an

inexpensive investment when compared to the risk of receiving the

wrong treatment.

Speak up

Being aware of treatment plan options and keeping records are of

little help if you are unable to ask questions or share concerns. But

speaking up can be intimidating for many people. If you feel that

way, remember to give yourself credit for what you know: You are the

expert of your own body. Remember, too, that you're paying for a

service. If possible, find a doctor who doesn't make you feel rushed

or uncomfortable. Speaking up may take practice, but with time, it

will get less scary and feel more natural.

To get the most out of a doctor visit or an appointment with another

health-care professional, it helps if you know what you want from it.

Perhaps you're seeking relief from a particular symptom. Or maybe you

have some questions about the drugs you're taking or about a new drug

you've heard about. Formulate a list of priorities and questions

ahead of time, and bring the list with you to your appointment. Bring

a notebook, too, to jot down your doctor's answers or other

information you want to retain. If you have a lot to discuss, you may

be able to request a longer appointment. Most providers will

appreciate your attitude of collaboration.

Have your personal documentation ready and in order for health-care

appointments: Bring your blood glucose monitoring records, insulin

dosage records, food diary or carbohydrate intake log, exercise

schedule, and any articles or clippings that have triggered

questions. Collect what you need several hours before your

appointment rather than as you are running out the door.

The information you provide needs to be accurate and truthful. If it

is not, your care may suffer. told his nurse practitioner that

he had not eaten in the previous eight hours when she drew blood for

a fasting blood sugar check. In fact, he had had a regular soft drink

on his way to the clinic, and it showed in his blood glucose level.

But because his nurse practitioner thought he was fasting (and

had brought no blood glucose monitoring records to refer to) she

doubled his dose of medicine.

Immediately after his visit to the nurse practitioner, saw the

clinic dietitian and complained of symptoms of hypoglycemia in the

mornings. When she asked how he had coped with skipping breakfast for

his fasting blood sugar check, he remembered the soft drink on the

way to the clinic and told her about it. If she had not called the

nurse practitioner and cancelled the new prescription, could

have developed dangerously low blood sugar.

A right and a responsibility

Did you know you already have a Patient's Bill of Rights? It was

developed in 1973 and revised in 1992 by the American Hospital

Association, a national organization that represents hospitals,

health-care networks, and their patients. Among other things, the

Patient's Bill of Rights lists a person's right to considerate and

respectful care, adequate information to make decisions about

treatment, privacy, access to medical records, and confidentiality.

You will find the Bill of Rights posted in hospital and clinic

settings. In addition, many states require that hospitals give people

a copy of these rights when they are admitted to the hospital.

As a self-advocate, you also have the right—and the responsibility—to

investigate different health plans, doctors, and clinics before

choosing one. Need surgery? Compare surgeons, talk to people who have

undergone the same surgery, and get a second opinion if you are

unsure of its necessity.

Learn what you can about all aspects of your health care and diabetes

care. Each day brings a new development in diabetes care, and

remaining up to date means actively pursuing your diabetes education.

As you learn more about diabetes and its care, set personal goals,

and ask your health-care team to help you make a plan for meeting

them. If you have abandoned any aspects of your self-management plan

over the years, your goals might start with the commitment to get

back to the basics of diabetes self-care. You may resolve to start

checking your blood sugar regularly or to look into diabetes

education classes in your area.

Self-advocacy means using all the resources available to see that

your health needs are met. It is a skill for survival. More

important, it is one of the keys to quality of life. As you learn to

be your own self-advocate, share what you've learned with others. See

to it that not everybody has to learn the hard way.

[Guest guest]

> The following article from the

> diabetesselfmanagement website,

> though lengthy, provides many

> suggestions to help us better

> deal with our diabetes challenges.

Wmabo, that article appears to be

based on US practice. But this group

is supposed to be international!

A lot of the article is valid for

diabetics in Germany except mainly:

1. Team

The whole " team " idea sounds good but

is a fiction (even in the USA, I bet).

Generally, in medical practice, it

appears to be every man for himself.

2. Treatment

The article applies basically also to

diabetes treatment in Germany.

3. Communicating with the physician

Mostly totally unrealistic in Germany.

The physician is paid for a few

minutes only (in Germany it is about

4 minutes per patient-visit). You

simply cannot expect a practicing

physician to give you a diabetes

education, unless he/she is making you

a present of his/her time.

Not all physicians are necessarily

good educators and tend to lapse

into medical jargon which can be

either incomprehensible or will be

misunderstood. A thorough basic

diabetes and nutrition education is

best obtained in a group and from a

qualified trainer using approved

training material. The physician

is there to treat your disorder,

not explain what is happening in

detail.

How much time per visit does a US

physician get paid for under the

various insurance schemes?

4. Insurance

This information looks like it applies

only in the USA. European health

insurance does not work that way.

5. Patient's Bill of Rights

That also sounds like a strictly US

thing.

My suggestion is that members who find

some useful information on the Internet

just post the URL so that we can go look

for it ourselves and see where it

comes from (and we don't bust the

copyright laws wide open!).

The very least would be to note as such

any information that is applicable to

only one particular country. It is not

safe to assume that what is valid in

the USA is also valid in the Rest of the

World!

[Guest guest]

In a message dated 6/7/2004 7:15:24 AM Pacific Standard Time,

atombombix@... writes:

>

> Hallelujah! Why not join/form a German diabetic internet group and lay off

> about how things are run on this group? 'International' should mean

> co-operation not criticism when things are not to one's liking or habitat.

>

> Joe

>

> Hi Joe, thanks for the chuckle! Hugs, Marilyn