Expanded role for RDNs can improve cardiometabolic outcomes in diabetes
A team-based approach to diabetes care that employs an expanded role for registered dietitian nutritionists can help people with type 1 or type 2 diabetes improve risk factors beyond blood glucose, such as hypertension and hyperlipidemia.
Diabetes is an independent risk factor for cardiovascular disease, and people with diabetes are at higher risk for myocardial infarction, stroke, heart failure and CV death; yet only one in two patients are aware of such risks, Gretchen Benson, RDN, LDN, CDCES, program director of the Women’s and Cardiovascular Health Science Centers at the Minneapolis Heart Institute Foundation, said during a virtual presentation at the Association of Diabetes Care & Education Specialists annual conference. Expanding the role of the RDN to include medical management has the potential to improve access, clinical outcomes and cost-effectiveness at a time when the emerging population health model expands care coordination to include adjustments in medication management.
“Achieving optimal diabetes care often requires frequent visits, medication adjustments and ongoing support for making lifestyle changes,” Benson told Healio. “Expanding and empowering the nonphysician team members in unique ways — use of medication therapy protocols and telehealth — can help more patients get access to and achieve improved health outcomes.”
The RDN can implement approved medication protocols to initiate and titrate diabetes medications and basic CVD preventive medical regimens, order associated labs, address factors interfering with meeting diabetes goals, such as cost, and consider complex diabetes management issues related to food, changes in conditions and medication. RDNs also offer comprehensive, holistic care by providing medication management along with medical nutrition therapy, Benson said.
Benson worked with a team to create HeartBeat Connections, a 10-year, primary prevention program, and the ENHANCED study, a randomized controlled trial of an RDN-led telemedicine program compared with usual care. For the interventions, participants spoke with a dietitian or nurse by phone monthly, with calls focused on optimizing major risk factors. Both programs addressed related cardiometabolic conditions, such as hypertension and dyslipidemia. All encounters were documented in the medical record.
Benson outlined steps for RDNs to implement a successful medication protocol within their practice:
- Use EMR data to build a case. “We learned about 2,500 individuals within our clinic system who were considered at high cardiometabolic risk but without active diabetes and heart disease were eligible for our [HeartBeat Connections] program,” Benson said. “When we looked at that [data] further, we learned that 65% were not taking a daily aspirin; of those with LDL cholesterol greater than 100 mg/dL, 81% were not taking a statin; and of those with a BP greater than 140/90 mm Hg, over half were not taking a hypertensive medication. This highlighted an opportunity to reach a broader patient population and help them achieve optimal care.
- Invite key stakeholders to serve on a committee to oversee the creation of the medication protocol. “Within our system, it was a team effort that included the medical director, clinic operations, a program manager, nursing and program staff,” Benson said. “The protocol was developed with the help of this collaborative group, and our health coaches, who were dietitians and nutritionists, were instrumental in creating this protocol also.”
- Collaborate with primary care; emphasize how you can support their relationship with the patient and help them overcome barriers. “Primary care providers in our rural communities were very supportive of this work and were instrumental in the creation of the protocols and ongoing use after the research ended,” Benson told Healio.
- Learn who ultimately must sign off on your protocol and how often it should be updated. “One of the things we learned is that, ultimately, you need to learn who signs off on this protocol,” Benson said. “For us, our facility had a medical operations committee that was in charge of doing that, and we needed to update that annually or as guidelines were released.”
- Collect data and continue to discuss regularly. “It is not only helpful to collect data at the start,” Benson said. “If you are going to do this work, it is important to continue to collect data to monitor progress and pivot as needed.”
“The RDN intervention did as well or better on primary care outcomes and significantly better on behavior change outcomes,” Benson said. “Use data to support your case and gain support for the use of medication therapy protocols and articulate your value in how you can enhance the patient and provider relationship and help the patient achieve better outcomes with higher satisfaction.”