In this episode of The Huddle: Conversations with the Diabetes Care Team, Jami Klein RN, CDCES, Senior Manager of Clinical Education at Dexcom, joins Davida Kruger, MSN, APN-BC, BC-ADM, Certified Nurse Practitioner at Henry Ford Health System, for a practical conversation on integrating continuous glucose monitoring into primary care. Together, they explore Dexcom’s CGM clinic workflow toolkit, highlighting how nurse practitioners and DCESs can streamline implementation, improve efficiency, and empower patients through data-driven care. This episode was supported by Dexcom. You can view Dexcom's CGM workflow by visiting dexcom.com/clinical-workflow.
Sloane Fisher
Hello and welcome to ADCES' podcast, The Huddle: Conversations with the Diabetes Care Team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm Sloane Fisher, Communications Manager at the Association of Diabetes Care and Education Specialists. One of the topics we've been particularly interested in lately as an association is supporting nurse practitioners and DCES' technology champions.
Today, Jamie Klein, RN, CVCS, and Senior Manager of Clinical Education at Dexcom will speak to Debita Kruger, a certified nurse practitioner at the Henry Ford Health System in the Division of Endocrinology, Diabetes, Bone and Mineral Disease. They'll speak on Dexcom's continuous glucose monitor clinic workflow toolkit and how nurse practitioners in primary care can integrate into their practices. Thank you to Dexcom for sponsoring today's episode.
Jamie, Davida, welcome to the huddle.
Jamie Klein
Thank you. Thank you so much for having us. We are excited to share with the audience our Dexcom Clinic workflow. Dexcom partnered with the International Diabetes Center and Health Partners Institute on this workflow. And you'll notice several health partners resources embedded within the workflow for both HCPs and for their patients.
So while this workflow was designed to support primary care providers with an easy way to incorporate Dexcom continuous glucose monitoring into their clinic workflow, we really wanted to highlight nurse practitioners today since we're seeing so many MPs managing diabetes care. And one of the reasons that we have Davida joining us today to share her expertise. While we are discussing MPs today, we want to point out how valuable CDCESs are, especially as a technology champion, and how important they are in supporting primary care. Davida, let's talk about what you're seeing in the primary care space and why nurse practitioners need to CGM with their patients with diabetes.
Davida Krueger
So you know the numbers with diabetes, people who have diabetes just continues to grow. There's more than 40 million people in United States with diabetes. And most of those people are not going to be seen in an endocrinology practice. They are going to be seen in primary care. Now, one of the things is we don't have enough endocrinologists. And within endocrinology, there are a ton of nurse practitioners because there are not enough endocrinologists. But within primary care, there's a group of nurse practitioners that now specialize just in diabetes or enhance the practice and focus on diabetes. So there are so many nurse practitioners that own the diabetes space within primary care. So I'm really glad we're having an opportunity to discuss that.
Jamie Klein
I am too, and I love seeing people with a passion for caring for those living with diabetes, just as you and I have made our career about helping people with diabetes. One thing to note is that Dexcom adapted the ICC or the Identify Configure Collaborate framework to design this simple workflow with a three-step process. So hoping you could help the listeners understand and describe the value of incorporating this framework into this workflow to help ease that transition to getting CGM into the practice.
Davida Krueger
Absolutely. And as you said, it is done with the International Diabetes Center and DEXCOM, which really excites me as well. And I looked at the references that were used, and I'm excited to say that my name was on one of those references. So that was kind of fun too. But it is a nice, compact way of looking about how to incorporate CGM into your clinical practice. And that's really important. If you're going to see diabetes, you have to.
So the first step is to identify. And there's two places you need to identify. One, to identify which device, and Dexcom has several that they can offer, the G7 or Stello, to the patient. So first you want to know what that is, and you want to introduce and identify for the patient who will be using the device. But within your practice, you want to identify who's going to support you to set it up in your practice. Are you going to use your MAs? Are you going to use some other RNs? Do you have educators in your practice? In some instances, they use the receptionist at the front desk who will help the patient upload, get the flow going within their clinic.
The second thing is to configure. And that person that you identify could also help you configure making sure that the patient is connected to your clinic. Not a difficult thing. And over time, Dexcom's made it even easier where you just give a code to the patient. I have it in my clinic, I can now see all of their data. And you don't have to look at it all the time, because I tell my patients, I'm only going to look at this data when you have a visit or you tell me you're having an issue. But if I'm configured and you have a problem, I can just pop in there and say, this is what I'm looking at and then collaborate.
We have to remind ourselves that we don't own the diabetes the patients do. They manage most of their diabetes. So we want to collaborate with the patients making sure they get all the education they need, whether it be through our educators, through our NPs, and the other providers. But the patient needs to own it and understand. So we want to go through every step that they have within their devices that they can take home and use to help them manage their diabetes.
And then there's actually a fourth step, which would be reimbursement. And reimbursement means, guess what, guys? You get reimbursed for looking at the data and you can talk to your business people of how to set it up so that there's a code that you just can use and when you look at the data, you get reimbursed. But we want to make sure that your clinic has a flow to it so that you really can benefit and so can your patients.
Jamie Klein
Thank you for pointing that out and I think it's great. We're going to get deeper into each of the steps as we go through this. But you know, when we follow this model, we're not just adding tech, we're improving care and reducing disparities and making life easier for both patients and providers. And when you pair it with education and follow-up, CGM really becomes a powerful tool to help drive better outcomes, which I know is something that you truly believe in. Let's start and discuss the workflow itself.
I’m hoping you could walk us through the process. And for those of you who are listening, you can open up the workflow on your browser, on your computer, or also on your mobile phone. And it's in the show notes if you'd like to click on it there. But if you wanted to just type it in, it's www.dexcom.com/clinic-workflow. So Devida, do you mind walking us through the steps as you are looking at website and let us know how you think this could be useful in practice.
Davida Krueger
Absolutely. So step one is to identify technological champion within your clinic, somebody that's going to help you help own this. And so they're going to help you set up your account. They're going to give the share code to the patient. They're going to make sure that you have what you need as you're seeing those patients on a regular basis.
Step two would be to configure and connect. And so the device that the patient has chosen, whether it be the G7 or the Stello, you're going to help that patient by getting them trained or using websites to get them trained. Then you're going to make sure they know what they're doing with their device, make sure that they have their sensor on and that they know how to use all of the intricacies within the device and that they're going to be connected to your clinic.
And then step three would be collaborate using the data. And that would be to collaborate with your healthcare provider team, so that I get to see your data and you know what that data means. I think it's really important since the patient wants to use it and will be using it at home, making sure they know what the data means. And then again, reimbursement, the IDC codes that will allow you to interpret the data, put that data in your chart, and you can in fact get reimbursed.
Jamie Klein
Fantastic. And I think each of those steps allows people within their own practice based on the resources they have to modify and make it work for their practice. And like you pointed out, it may be an MA, it may be someone at the front desk, it may be a nurse, but that can all be accomplished with a team and helping identify those people. As far as reimbursement, I know you mentioned that's the fourth step to help people get paid for the work that they're doing. But let's also talk about... So clarity is where you're going to get the information that you need. Can you talk about how you might copy and paste or how do you record that information within a note to help people with that reimbursement process?
Davida Krueger
Absolutely, and I think reimbursement is very important because we should all get paid for our work and people do look at what we're doing. So all we do is we go to clarity, we pull out the graphs that are important to us that we're going to be making decisions on. And also I like to put it in the chart because I think then the person coming behind me can take a look-see and I use it from visit to visit. So I cut and paste what I need. I put that into the chart. And then I have a little smart phrase that goes under it that just says, evaluated it. This is what I saw. These are the changes I'm going to make. And that's enough information for me to be able to use the billing code for reimbursement.
The reimbursement varies by whether it's Medicare, Medicaid, or commercial. But it is certainly worth the time and energy to be able to bill for the work that we've done.
Jamie Klein
Fantastic. So let's talk a little bit about time because I know a lot of people are pressed for time when they're seeing so many patients in one day and we know that every clinician time is of the essence. Can you speak a little bit about how once established the workflow within an office, how does this contribute to efficiency and productivity and do you have any examples that you've witnessed that you could share?
Davida Krueger
Well, it's really interesting because I do hear sometimes people like, that's so much work. The reality is if I'm going to provide high quality diabetes care, it actually cuts the time out of my day. Because if I have no data, how do I make a decision? And if I'm trying to scroll through a blood glucose meter or even if a patient hands me one or two or three blood sugars a day, my brain is trying to wrap it around where once you have a workflow, the person comes in. If it's on their phone, it's automatically uploaded into Clarity. If it's on a reader, we can quickly, a receiver, can quickly upload it. And because of the data there, it really helps me wrap my head around what I'm going to do. So I had recently had a patient come in and said, I ran out of sensors about two months ago, and I've been doing two blood sugars here or there most days, not all days. But I can tell you my average glucose is 180. And then his A1C came back 8.4 and he's on four injections a day. And I'm like, my goodness. So what do you think I can do with that lack of data? Where if I had a sensor data, I could see, okay, overnight his blood sugars look great after meals they're running high, or, you know, he's not having any hypoglycemia so I can increase his insulin. So it makes the visit go so much quicker.
And if you set it up, where the patient's already connected to you in the clinic, all you're doing is opening it up, taking a look-see, and making some quality decisions. You get to look at the time and range. You get to have a good conversation with the patient so they understand what you're looking at and why you're looking at and why you're making decisions.
And then sometimes I can say, listen, you're always high after breakfast. Is there something different that goes on? I'm such a rush to get to work that I don't always remember to take my insulin. Well, let me show you what that means when that happens.
So I think it's just putting your workflow there and it actually makes your day so much easier and the quality of the decisions you're making are so vastly improved and also what you're teaching the patient to be able to own their own diabetes. If you're seeing them every three to six months, they're making those decisions in between visits and you want them to have quality data.
Jamie Klein
You made so many important points during that. I want to bring up all of them again just to make sure people heard them. But I think that it's really important. It's the quality of the decisions being made and it's empowering people to look at their own data. So this data is something they are able to see the same thing you see in between visits. And this will help collaborate within that time as well. As you know, they can get in touch with you. They can help you see that. And I think one important thing when it comes to time is anything new within a practice or within a day of taking care of people, it can take a little more time upfront just to get comfortable, just to be able to understand how to use CGM. But like you're saying, in the long run, it's really making your clinic visits more efficient for you and your patients.
Davida Krueger
Yeah. And I think too often if we don't have that data, our patients not wearing a sensor, they're not engaged in their diabetes care. And so when they come in for a visit, it's not, their thought process is not engaged in their diabetes. And that takes longer to get to the crux of the issues that you're trying to help the patient with. So if I give a sensor to a person, there's enough research that I'll show you, even if I never make any changes or I never discuss it with them, their A1C improves because they become part of the destiny of their diabetes and they see the data and they make changes. And they, like the gentleman whose blood sugars are high after a particular meal because they're forgetting the insulin, if they see that, it's more apt to help them remember to take the insulin than not. And the patient who needs to be more physically active, the cues that CGM give them.
And that helps my workflow when they come in because like I said, I just go to Clarity, I pull it down and I say, let's look at this together. And here's where I'm seeing there's a problem and then I can move on. And especially in primary care, if you think about, they don't just come in for their diabetes, even though it's these nurse practitioner doing a magnificent job, they're also coming in for maybe a cold or a flu or vaccines. And so if we can carve out something like CGM to help them in primary care, helps illuminate the data they need to look at, that really does help you long term. So if we set up your clinic right, it's going to help you long term.
Jamie Klein
Absolutely. And I think some of the research you're alluding to, people are making those choices and decisions in real time, seeing it in real time, and there's a big improvement in their time and rage within the first 10 days of wearing a CGM, which I think is incredible. So tell us about one resource on the Dexcom workflow that you think every clinician should bookmark.
Davida Krueger
Well, I think you just need that one page with time and range and AGP. I might look at 72 pages, but I don't need to. And the more I practice, the less I need. But if you just look at that one page, it's going to tell you time and range. It's going to tell you if the patient has hypoglycemia. You get to look at the last two weeks superimposed. And whoever came up with that is brilliant because, and I think it's my friend Rich Bergenstahl, because
Because it lets you see everything that you need to see and focus. Okay, you look great overnight. Okay, you look great at noon. Okay. And then I can say, wait a minute, at 10 o'clock, let's go down to the dailies. it's only one day. So if you just use that one page, and then if you need to go look at others, you're fine. But just look at that one page. You've got everything you need on one
Jamie Klein
And so under the resources on the workflow, there is something for clinicians called No Learn Act, and it helps them look at the AGP report you're talking about and quickly make some decisions and assessments, and it helps them learn how to do that. So if you're new to interpreting data, there's a resource there that helps you. There's also a resource that I love that is using CGM data in addition to the medication guide that was created by Dr. Bergenstahl's team and Dr. Martin's at the International Diabetes Center that helps people learn all the medicines with diabetes. So it's really a wealth of information, not only for the clinician, but for them to be able to give their patients as well at the end of a visit.
Davida Krueger
And Jamie, I just want to say too that I don't want people to be intimidated by the data because as you've described, it is really easier than you think to look at and it really just takes you focused into that and you can use the resources. And so once you get through a couple of patients, you become a pro as the clinician and the patients are reading it as well.
Jamie Klein
One of my favorite questions is simply to ask a person with diabetes, what do you notice? They'll have something to say. We'll see what it is each time. It'll be different. But people look at their data when they have it available. So to change the subject a little bit, how do you see CGM fitting into the broader goals of value-based care and population health management?
Davida Krueger
Well, first of all, you know that I believe CGM is a right, not a privilege, and that we should be offering CGM to all people with diabetes. And the American Diabetes Association stands of care in 2025 basically said that you don't need to be on insulin to benefit. When it first came to market, it was for hypoglycemia. We now realize it's to manage diabetes plain and simple. So I think people have embraced that and we need to not only have insurance companies embrace that, Medicare's embrace that, Medicaid's embrace it, it needs to come far up there. We'll all agree to that. So I think when we look at how many people have not been offered it, that's where we need to look at healthcare and population and all that kind of stuff and making sure that the healthcare providers are much more comfortable with prescribing and using CGM. So I think that we need to get it out to improve healthcare across the horizons of all people with diabetes, and then we can see an improvement in the things that you've described.
Jamie Klein
I think that's an excellent point and I think it's so important that people are offered. People may not be ready for it and that's okay. It just is offered so that when they are ready they know it's something available to help them.
Davida Krueger
Well, I think people use it in different ways, and that's okay too. And the healthcare providers use it in different ways as well. They do not have to spend a huge amount of time interpreting, quick look, see, you're doing great. But I think that we have to recognize it has to be comfort level from the healthcare provider. And I think that's why our nurse practitioners are shining as well as offering it to patients.
Jamie Klein
So I think I know your answer, but will you share with the audience on why you think adopting this CGM workflow is important for them to do right now in clinical practice?
Davida Krueger
Well, I kind of gave it away, but I think that the CGM is a right, not a privilege. And whatever we can offer the healthcare providers to make their practice a little bit easier to understand how incorporating this workflow eases your practice, makes it better for you. And incorporating CGM is the right way to go for a better outcome for people with diabetes. And it really does improve the life of both the patient and the healthcare provider. Everybody needs to adapt and adopt continuous glucose monitoring if they're going to be managing diabetes and patients just deserve the opportunity. They really do.
Jamie Klein
I completely agree with you. And I think that you've given so many points, so many valuable topics and discussion for the listeners to think about. But just curious, if there's one takeaway that you could leave everyone with today about our discussion, what would that be?
Davida Krueger
Not to be afraid of CGM. It really is your friend, both in how you practice as well as the need for the patients, and embrace it. Just embrace it, and I promise you, you'll find that it not only is easier than you think, but it improves the outcomes of what you're trying to accomplish in the world of diabetes.
Jamie Klein
Beautiful. And I just want to leave the listeners with the fact that Dexcom has a CGM for anybody ages two plus. There's G7 that's available by prescription and Stello that can be purchased without a prescription on Stello.com for those not on insulin who are over 18 years of age.
Davida, I always love talking to you. I love your insights. I love your passion for CGM and diabetes management. And thank you so much for joining the conversation today.
Davida Krueger
Thank you for having me.
Sloane Fisher
Jamie, Davida, both thank you again for taking the time to join us for this episode of The Huddle and for sharing your expertise. And thank you, Dexcom, for sponsoring today's episode.
Thank you for listening to this week's episode of The Huddle, Conversations with the Diabetes Care Team. Make sure to download the resources discussed in today's episode. You can find them linked in the show notes at adcs.org/podcast. And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients.
Learn more about what ADCS can do for you at adcs.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare provider for any medical questions.