Using Continuous Glucose Monitoring Technology in Care Management for Seniors with Multiple Chronic Illnesses

An estimated 33% of adults aged 65 or older have diabetes.1 In April of this year, Medicare expanded coverage for continuous glucose monitoring (CGM) systems to include all insulin-dependent people and those with a history of problematic hypoglycemia. Chuck Henderson, chief executive officer of the American Diabetes Association, said in a statement: “We applaud CMS’ decision, access to a continuous glucose monitor, is a potentially life-saving tool for diabetes management.”

By measuring interstitial glucose levels on an ongoing basis and transmitting measurements to an external monitor or smart device at regular intervals, CGMs allow for more precise management of glucose levels.2 CGM technology is expected to improve health outcomes for many Medicare beneficiaries with diabetes, while reducing Medicare spending for the treatment of diabetes-related complications.

The clinical benefits of CGM systems have been demonstrated in numerous studies. These benefits include reductions in hemoglobin A1c (HbA1c), fewer severe hypoglycemia events, increased time within target glucose range and reductions in time below range. A significant association has also been found between CGM use and reductions in both HbA1c and diabetes-related hospitalizations.

Adoption of CGM by older adults is particularly important for several reasons. “Older patients are more likely to have hypoglycemia unawareness, a reduced ability to produce counterregulatory hormones, and an altered metabolism that increases the risk of severe hypoglycemia (SH) due to polypharmacy. The risks associated with SH include falls leading to fractures or other injuries, cardiovascular complications, and temporary or permanent cognitive impairment.”3

Medicare beneficiaries with CGM devices will still be required to meet with their treating practitioner in person or by telehealth to assess adherence with their CGM regimen and treatment plan. However, while this expansion in CGM coverage will significantly increase demand for this technology, many clinicians are still reluctant to prescribe this diabetes care management technology.

The expansion of coverage for CGM has addressed the most common reason (cost) for resistance to CGM adoption but there are still patient and provider concerns with ‘ease of use’ and what to do with all the data the CGM devices produce.4

“For patients with diabetes, wearable sensors such as continuous glucose monitors (CGMs) are at the heart of this paradigm shift which is presenting massive quantities of physiological, behavioral, and environmental patient-generated health data to the healthcare professional (HCP). This data can be collected, transmitted, presented, stored, and processed in real time to be used in decision support software or algorithms for an HCP to review in real time or asynchronously. To be most useful, the data must integrate into a patient’s electronic health record (EHR)… None of the most common CGM applications connect directly with the hospital EHR, and the only way the CGM data can be analyzed is by viewing the screen or printing a report. A screenshot image can be saved in the EHR, but the data is not annotated and it will be difficult later to find the screenshot. This is less than ideal because the data is (1) not structured and (2) difficult to search for… currently, very few healthcare organizations have successfully integrated continuous glucose monitor data directly into the EHR, and most of those have done so with the assistance of third-party integration engines or data aggregators.” 5

Providers who are reluctant to prescribe CGM should consider engaging an intermediary care management system that can use direct secure messaging protocols to provide the patient CGM results as structured data to their EHR. This is easy and inexpensive to establish – to be certified, your EHR vendor must include direct secure messaging.

The intermediary care management system should support a diabetes clinical pathway that prescribes CGM in conjunction with a personalized chronic care management (CCM) care plan for their senior patients with multiple chronic illnesses including diabetes.

Ideally, this protocol should include incident-to virtual multi-disciplinary clinical staff (nurse, pharmacist, dietician, social and community workers, etc.) who would engage the patients virtually to:

Educate the patients and retrain them as needed on the use of the CGM system.
Assist with support and calibration of the CGM devices.
Address patient non-adherence.
Document any related personal factors, diet and/or lifestyle psycho/social conditions occurring in conjunction with a CGM out of range reading.
Use synchronous and asynchronous communications based on the CGM and supporting data to counsel the patient to promote healthy behaviors.
Coordinate care with all of the patient’s identified caregivers and stakeholders.
Submit the patient care documentation to the treating physician’s EHR for review
Escalate any alerts as directed by the treating/referring provider using direct secure messaging with the Provider’s EHR

By:

Milo Anderson, M.D. Dr. Anderson is a physician and medical director. He was an early adopter and advocate for telemedicine and digital health. He is currently the clinical team director for CCARE HEALTH and a member of the Advisory Board for SAM GROUP

John Byars is a Senior Vice President for Strategy with SAM GROUP, a healthcare consulting firm specializing in business process outsourcing solutions for healthcare organizations. He is also a Director for CCARE HEALTH.