“It’s a souped-up diabetes clinic,” says Fernando Ovalle, MD, Director of the Multidisciplinary Comprehensive Diabetes Clinic at UAB. Started about three years ago, the Clinic constantly expands. “We have different subspecialties within the umbrella clinic. It’s a convenient one-stop service provided to patients with diabetes.”
The Diabetic’s Retreat
The most recent one-day program, appropriately dubbed the One-Stop Diabetes Clinic, introduces all new diabetes patients to the daily challenges thrust on them by the condition. “It’s very intensive, almost like a diabetes retreat,” Ovalle says.
Patients arrive in the early morning, and Clinic personnel draw blood to be sent immediately to the lab for analysis. Having fasted, they all go right to breakfast. “It’s more of an eat-and-learn activity,” says Ovalle.
Starting during that meal, the diabetes educator spends the morning — and lunch — on the fundamental basics of living with diabetes, including the possible complications, disease management, and anything nutritional. The patients also meet one-on-one with the diabetes educator in an hour-long session for more intense and private counseling.
The lengthy time spent with the same educator offers the clinic specialists a unique glimpse at these patients’ attitudes and behaviors. “The educator usually finds out a lot of interesting and important things that we wouldn’t find out as doctors. By watching them eat and take their insulin, she sees the bad techniques and the things we’d have no way to pick up on during a normal doctor’s visit,” Ovalle says.
Ovalle admits the day can be wearing on older people, but “it’s a very efficient use of their time.” It’s especially useful for out-of-town patients who require long commutes to reach any specialists. “It’s so convenient for those people. They get to see everybody in one day.”
Afternoons are spent with the doctors. Everyone sees an endocrinologist who specializes in diabetes. “By the time we see them in the afternoon, we have their test results,” Ovalle says. “So we’re able to pull together their history, lab data, and the information from the educator — who was been with them all morning — to guide our management decision.”
Each patient, as needed, also sees a podiatrist and an ophthalmologist. “We encourage patients to see both specialists if they do not have one or have not see one in the last year,” Ovalle says.
Post-hospital Transition Care
UAB opened another new diabetic program three months ago. The first of its kind in the nation, the Acute-to-Chronic Transition of Care Clinic (ACTC) helps patients regain control of their diabetes after a hospital stay. “The problem with diabetes is that it can’t get regulated in just a few days. It takes at least a week or even longer,” Ovalle says. “So diabetics end up with a high readmission rate because of complications.”
ACTC, also called the Diabetes Bridge Clinic, sees the newly released patients within a week of discharge. The patients then attend each Friday for no more than a month.
“It’s usually under control after the second visit,” Ovalle says. “Then they go back to the care of their primary doctor. We don’t want to and can’t take over the care of them all, we just want to make sure they’re okay once they leave the hospital, because it’s a critical period.”
Ovalle says diabetics new to insulin will benefit the most from participating in ACTC. “If they had to go on insulin while in the hospital and have never taken it, then they don’t know what they’re doing when they get home.” And if their primary care physician has not been told about the hospital stay or may not be able to see the patient for a week or more, ACTC fills that gap.
Prime candidates for the Bridge are also those patients placed on intensive insulin therapy or those needing strict glucose control, like people who have undergone open-heart surgery or transplants.
So far, ACTC has served more than a score of diabetics in its first 10 weeks. “It’s been easier than I thought it would be to get their diabetes under control,” Ovalle says. “A week after seeing them, it’s already controlled.
“They’re very motivated. They’re all very responsive to instructions, unlike what we normally see in the regular diabetes clinic. They want to do better, so they won’t end up back in the hospital,” he says.
Referrals to the Diabetes Bridge Clinic have been slim, but Ovalle is not unhappy with the slow growth. “We don’t want to open the flood gates, because right now it’s only me, and I don’t want to have to say no.”
But marketing has begun to UAB hospitals and doctors. “We’re targeting UAB, but anybody’s welcome,” Ovalle says. Reimbursements work the same as with any other clinic.
“We serve as place to call with questions during a difficult and uncertain time of adjustment,” he says. “We have their records, and we know them. It’s a little bit of a fail-safe type of clinic while they recover.”
Diabetes Clinic Just for Adolescents
by Jane Ehrhardt
UAB runs a unique diabetes program that caters only to adolescents. Participants must be 18 to 22 years old. “It’s almost like a club. You have to be a certain age to belong,” says Fernando Ovalle, MD, Director of the Multidisciplinary Comprehensive Diabetes Clinic at UAB’s Kirklin Clinic. “But it’s an environment where they get to meet other adolescents with the same problems, as opposed to mixing with amputees or old people.”
The clinic focuses on diabetics forced to graduate from their pediatric endocrinologist when they reach 18 years of age. “Pediatrics is very paternalistic,” Ovalle says. “They have more financial means to provide assistance, and these things go away when the patient reaches eighteen. So they feel like somebody's pulled the rug out from under them, and they get lost.”
Opened about 18 months ago, twelve adolescents currently participate every other week. “It’s a difficult time of life for them,” Ovalle says. “They’re not yet ready to be on their own. They’re still children, even though they think they’re adults.”
Some of them lost their insurance when they turned eighteen, and have no concept of how to navigate the healthcare system. They also lose faith when they’re told “no,” rather than knowing to look for other options.
“So they don’t have money for test strips or insulin or syringes,” Ovalle says. “And if they go to a regular clinic, they better know how to contact their insurance and know what it provides and what it doesn’t, because that clinic treats them like they’re an adult.”
But at UAB’s clinic run by Brooks Vaughan, MD, an expert in adolescent medicine, they find help learning the system from an adult’s perspective. And besides having access to the usual specialists, they also gain access to social workers.
“They have a lot of peer pressure on them and pressure to sustain themselves. We want to make that a little bit easier for them,” Ovalle says.