Mayo Clinic educators Nancy Klobassa-Davidson, RN, BSN, CDE and Peggy Moreland RN, MSN, CDE juggle many responsibilities including treating patients, writing a successful diabetes blog, and continuing in the institution’s team approach in bringing forth that philosophy to its outlying clinics.

By John Parkinson, Clinical Content Coordinator,

Diabetes educators Nancy Klobassa Davidson, RN, BSN, CDE (pictured, right) and Peggy Moreland RN, MSN, CDE (pictured, left) have it good.

They work at the world renowned Mayo Clinic in Rochester, Minn., which was ranked numbered one for diabetes and endocrinology by U.S. News and World Report for 2010-2011; they have access to some of the latest treatment technologies and protocols; and they have an important voice, which they apply in writing their diabetes blog.

As expected, a typical day for Klobassa Davidson and Moreland and fellow CDE`s who work at Mayo Clinic is anything but that. It may involve being in many settings and serving in many capacities including working in the main outpatient clinic, making follow-up lifestyle phone calls to patients, visiting the outlying clinics, or working with other healthcare providers in the hospital to aid patients in getting their blood sugar under control.

In addition to seeing patients, Klobassa Davidson and Moreland maintain a blog on Mayo Clinic’s health information site, Simply named, “Living with Diabetes” they have been writing the blog for over two years, and they say the feedback from readers has been very positive. Blogging is one more way for Klobassa Davidson and Moreland to reach out to people with diabetes, especially in a world where people are clamoring for accurate and timely information on the chronic disease.

The two educators complement each other. In addition to her work on the blog, Klobassa Davidson, the senior member of the two, wrote a preface for the clinic’s 2009 book titled, “Mayo Clinic on Managing Diabetes.” Moreland, on the other hand, holds a very personal connection to the disease. Two of her sons have type 1 and several other family members have type 2.

Nevertheless, even in having great healthcare careers in a successful medical institution, Klobassa- Davidson and Moreland still encounter some ongoing care challenges.

For example, their ability to perform follow-up care can be difficult because many of their patients are not local. With Mayo’s outstanding reputation, patients come from all over the U.S. and much of the world to receive care. Often these patients come in for treatment of a disease other than diabetes, and in these circumstances, Klobassa and Moreland and fellow CDE`s help get a patient’s glucose under control so they can undergo surgery. Post-operative, these patients may spend a limited amount of time in the hospital and then fly home. While there are follow-up phone calls from the CDEs, it can be challenging to track these patients, and nothing is as good as an appointment with a diabetes educator.

Overall, one of Mayo’s biggest philosophies is to put a special emphasis on “patient comes first” philosophy, so they use a team approach for treating patients with diabetes. While in the hospital, patients have access to a specialty team that includes an endocrinologist, advanced practice nurses, certified diabetes educators, and dietitians.

Mayo’s diabetes education program includes many components. In each of the subsets, various providers will be responsible for the care of patients. For example, in the outlying clinics, chronic care managers take the role of health coaching. Klobassa-Davidson and Moreland and fellow CDE`s are looking at better ways to provide diabetes education access to primary care through a team approach.

With so many interesting facets to Mayo’s programs and the educators’ various responsibilities, recently sat down with Klobassa-Davidson and Moreland and the following responses are some of the highlights from the conversation: Mayo Clinic has been ranked number one by U.S. News and World Report for diabetes and endocrinology. Is there something specific in Mayo’s style or patient management approach that has helped it to be viewed as a leading hospital in these medical specialties?

Klobassa-Davidson: Mayo Clinic has one of the largest concentrations of endocrinologists in a single location and is home to some of the world’s leading endocrinology researchers. Patients at Mayo Clinic can see a provider who specializes in a particular endocrine specialty like bone, thyroid, lipids, nutrition, diabetes, and the pituitary gland and adrenal (PGA). These specialists are able to keep up to date on care and confer with one another in person and via electronic medical records. Can you give an overview of how patients are referred to you within Mayo’s system?

Klobassa-Davidson: Mayo is a unique clinical practice as we have patients who come from across the U.S. and from foreign countries. Patients are usually referred in from their hometown provider, but they can be self-referred by going online or calling for a clinic appointment. Generally speaking, diabetes is not what brings people to Mayo; it is usually something like back pain, cancer, heart surgery, or a rare condition.

Diabetes is addressed in the initial work-up, and we may need to be involved to help control blood glucoses prior to surgical procedures, chemotherapy, or tapering of pharmacological agents such as steroids. Diabetes education is often directed to those immediate needs.

We try to follow-up, but it can be difficult with patients not from the area. Our local patients are followed through our community medical clinics. Can you explain how patients in the hospital are covered in terms of their treatment?

Klobassa-Davidson: Hospital patients are followed by the diabetes consulting service (DCS), if referred. The service is run by nurse practitioners, physician assistants, and educators are included. An endocrine fellow or staff does oversee the nurse practitioners and they manage the blood glucoses by consult. Also education is done more on an emergency case basis in the hospital. In thinking about applying more of a team approach to patient care in the outlying clinics, have you developed a timeline for implementing this?

Klobassa-Davidson: We don’t have a timeline.

Moreland: In the last few years, chronic disease care managers have coordinated care for patients who have fallen behind in their control. Sometimes, providers are confusing them with diabetes educators, because they are doing lifestyle management calls. As such, we are not seeing as many patients as we should be and we are sitting down to coordinate some possible solutions. We are also trying to decipher what is best for the patient in terms of education. We are trying to develop a protocol revolving around medication regimens, when to follow-up by phone, and when to bring people in for appointments.

Klobassa-Davidson: We do offer team management approaches in some of our classes like the three-day intensive insulin class. We have a staff endocrinologist, endocrine fellow, a CDE, dietitian, a physical therapist, and social worker. Patients come from all over to attend this class.

We also have a diabetes technology clinic team approach that is staffed with an endocrinologist, a fellow, and a CDE. We specialize in the insulin pump and glucose interstitial sensing. These are just a few examples of the many components to our overall program. Why the decision to start the blog and what has been the response?

Klobassa-Davidson: Mayo Clinic’s health information web site, has been providing health information to the public since 1995. A few years ago, we began adding blogs to the site. The diabetes blog was one of the later ones brought to the site, and I think that is because diabetes is such a complicated disease process and diabetes management has to be individualized to meet each person’s needs. One of the challenges Peggy and I face when writing is addressing both type 1 and type 2 diabetes, since they actually are two different diseases that can cause the same complications. We have had an excellent response from readers. How do you come up with ideas for the blog?

Klobassa-Davidson: We are always on the alert for ideas, so we continuously look at articles, websites, and books, and when we do come up with one, we write it down and put it in a file.

Moreland: When we are in the clinic and we come across a common theme or question from patients we will use them as well. Speaking of the blog, Peggy, your two sons have type one diabetes. Did their diagnosis play a role in your getting into diabetes education initially?

Moreland: It was part of the reason. Only one of my sons had it at the time I started this position. They were both diagnosed in their early 20s and both in the military. My youngest son was diagnosed almost two years ago. Nancy, you have been working extensively with insulin pump therapy and continuous interstitial glucose sensing. How are these technologies changing patient management?

Klobassa-Davidson: While we do live in a technology world, it is still not for everyone. Nonetheless, I have seen insulin pump therapy improve control and quality of life for many of my patients who are type 1 and some who are type 2.

Glucose sensors are a great tool, especially for people with hypoglycemia unawareness. People that use the sensors need to be tech savvy, patient, and realistic about their expectations of the glucose sensing. This technology needs to be further developed so that it is a little more user-friendly, accurate, comfortable, and affordable. Are you seeing one patient population gravitating more towards these contemporary technologies?

Klobassa-Davidson: In training younger people on the pumps, they just take off in using them. They are running ahead of me when I’m pushing buttons. For the sensors, they can be really finicky and take more time in working with them, and younger people want to be able to do short cuts. On the other hand, I’m seeing older patients who range in ages from their 40’s through their 60’s who are interested in the sensors. What do you see as the greatest challenges facing CDEs today and how would you like to see them addressed?

Moreland: I think the biggest challenge for CDEs is being able to do what is best for patients regardless of reimbursement issues. Insurance reimbursement and other financial matters often determine the types of meters and insulin patients can get, or if a patient can use a pen or a syringe. Many times, we have patients who can’t afford their insulin. I would like the care team to have more latitude in determining what’s best for each individual patient in terms of medications and meters. One of the sentiments out there is this idea that there is a disconnect between some CDEs and primary care providers, especially with the latter group getting their patients to visit with educators. Have you had to deal with this access barrier? If so, how did you overcome the challenge?

Moreland: Although diabetes self-management education is a crucial component to diabetes care, the number of patients we see in these settings is disappointingly low.
I think visibility is a problem. We are not present on a day-to-day basis. We go to the outlying clinics one day a week. We are developing a one-day diabetes clinic with a team approach at each of these clinics, and it is still a work in progress. The team would include a diabetes mid-level provider, CDE, care manager, and the pharmacist.