Diabetes and Primary Care


Diabetes Interview | CareMore Health

Q&A with Dr. Paul Mikulecky, Chief Medical Officer, CareMore Health

Are there notable trends in diabetes, such as higher incidence or age of onset?

Yes, the U.S. population is trending toward higher rates of obesity.  This increase in obesity correlates to not only an earlier onset of type 2 diabetes, but a higher predominance in our population.  With the increased incidence at an earlier age, clinicians are faced with managing more complications related to this chronic disease.

As a primary care physician, how do you work with diabetic patients?

With diabetes, our primary care physicians work to understand the patient and the driving influences. Ultimately we're looking at diet, exercise and what we can manage from a medical perspective. Yet, as you can imagine, there are underlying nuances.

You may find their diet is related to cultural or behavioral influences – think about stress eating. It may be related to income and availability of healthy food options, i.e. food deserts.  As we look at a patient holistically, we need to think about the patient’s barriers to eating a healthier diet. Fruits and vegetables cost more than carbohydrates and may harder for patients to access. Patients may not be familiar with nutritional concepts, such as carbohydrates and how food is metabolized in the body.

Our clinicians work to find the patient's starting point based on who they are, where they are, what they know about nutrition — and how we help them evolve to a healthier lifestyle. If we can help them eat better and exercise more, we may be able to control their diabetes with fewer medications. Contrast this with somebody who's eating poorly or not exercising — they will require more medications.

What are some features of the diabetes disease management program at CareMore Health?

The disease management program takes a holistic approach: We have pharmacist on staff to help with medications. We perform education around good nutrition and meal planning. And we have behavioral health clinicians to address depression, anxiety or impulsive behaviors around eating.

Our disease management approach tries to establish where the patient is today, how he or she got there, and working with them to understand the cause and effect relationships. With diet, what happens to your sugars when you check before and after eating certain meals?  Knowing that, how do you adjust your eating style and medications to best control your diabetes?

How do diabetic patients benefit from a multidisciplinary clinical team approach, such as CareMore Health’s advanced primary care model?

A multidisciplinary team approach allows us to play to different strengths on the team. Our diabetic nurse practitioners and physicians can do medical management. However, they may rely on the expertise of others on the team to assist with other aspects, such as managing the cost of medications and food. The team will bring in a social worker, who can connect the patient with resources to pay for their medications or make healthier food choices.

The team also can bring in a therapist to work through behavioral health issues like depression and anxiety. A pharmacist can find drug discounts, identify drug interactions and side effects, or suggest drugs with a better side-effect profile.

Our objective: Whether it’s behavioral health, social determinants of health, social, economic or educational — meet the patient where they are and bring resources to treat that patient holistically.

How does the home environment affect diabetes?

Our mission is the right care at the right place at the right time. And part of that is understanding the patient: Are their eating habits based on how they've always eaten and how their family has eaten?

We may need to provide nutritional education or support to modify a family's eating style. Because if one family member is a diabetic, others may be at risk. In the home environment we focus on the driving factors: Is this an isolated case or is this an opportunity to change the family’s lifestyle? How can we work upstream, break old cycles and intervene early?

What are your thoughts on remote patient monitoring and wearable technology?

They are powerful tools when used appropriately and with the right patient population. We're exploring expanding the use of wearables to transmit blood sugar readings and engage with patients in a virtual experience. As a patient is logging their blood sugars on a device, we could capture that information and make recommendations via telemonitoring. It would allow us to stay on top of situations in real time, rather than after the fact. There are multiple areas in development.

Are there related conditions with diabetes we need to watch for?

With Type 2 diabetes, there is a correlation with increased weight and body mass index, accompanied by high blood pressure and elevated cholesterol. For some patients, a 10 percent loss of body weight can produce health benefits such as lower blood pressure and fewer cholesterol medications. Unfortunately, when the patient crosses a certain weight or BMI threshold, other comorbidities kick in which increases the risk of heart attacks, strokes and other complications.