We know research is crucial for making continued advances in diabetes care for all populations. Rachel Stahl-Salzman, MS, RD, CDN, CDCES, and Kerri Knippen, PhD, RDN, LD, BC-ADM, FAND, join us on The Huddle to talk about their latest research projects related to pregnancy in diabetes, some of the outcomes and learnings of each study, and how diabetes care and education specialists can be leaders in this work, even without a research background. View Rachel's research poster diving deeper into this topic here: Annual QIPS Symposium | Weill Department of Medicine (cornell.edu) Learn more about Kerri's project here: https://www.eeds.com/enduring_material.aspx?AIN=005243415&SIN=230144&Display_Portal_Nav=true https://bsmh.zoom.us/rec/play/dNYY9PJAVNjh_wJCglFQuYOU9GYRTC4JYP1xEr3eqd5037qGu1kvWbgs0Mw35SdAhBtm-W66tyZCnDv8.FBeiYIeEMAKXck4F?canPlayFromShare=true&from=share_recording_detail&startTime=1713455116000&componentName=rec-play&originRequestUrl=https%3A%2F%2Fbsmh.zoom.us%2Frec%2Fshare%2F6jgesPiUBq5EIbX8P7K0pzRJ4yKEb-HPxmBMMhqUZxbBBqREek8OvlNR7vh3aQR2.hQwbtfqHOQ8tp3uF%3FstartTime%3D1713455116000 Join the poster presentations at #ADCES24 to learn even more about Kerri and Rachel's work! Learn more and register for the conference here: ADCES24 (adcesmeeting.org) Learn more about the ADCES Foundation here: ADCES Foundation
We know research is crucial for making continued advances in diabetes care for all populations. Rachel Stahl-Salzman, MS, RD, CDN, CDCES, and Kerri Knippen, PhD, RDN, LD, BC-ADM, FAND, join us on The Huddle to talk about their latest research projects related to pregnancy in diabetes, some of the outcomes and learnings of each study, and how diabetes care and education specialists can be leaders in this work, even without a research background.
View Rachel's research poster diving deeper into this topic here: Annual QIPS Symposium | Weill Department of Medicine (cornell.edu)
Learn more about Kerri's project here:
https://www.eeds.com/enduring_material.aspx?AIN=005243415&SIN=230144&Display_Portal_Nav=true
Join the poster presentations at #ADCES24 to learn even more about Kerri and Rachel's work! Learn more and register for the conference here: ADCES24 (adcesmeeting.org)
Learn more about the ADCES Foundation here: ADCES Foundation
Kirsten Yehl
Hello, and welcome to ADCES's 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 Kirsten Yehl, Director of Research and Development at the Association of Diabetes Care and Education.
We know research is so important in making continued advances in diabetes care for all populations. Today I'm joined by Rachel Stahl-Salzman and Kerri Knippen, who recently finished up separate research projects both related to care for people with gestational diabetes. I'm here to discuss with them how each of these projects came out, what they hope to learn from each study, and what they've learned along the way that can be helpful knowledge for any diabetes care and education specialists or member of the care team. Kerri and Rachel, welcome to The Huddle.
Rachel Stahl-Salzman
Thanks so much for having us. I've been listening to this podcast for years and really excited to chat with you today.
Kerri Knippen
I'm also very happy to be here. It's an exciting opportunity to share some of our work and hopefully inspire others in the field to participate in this type of work.
Kirsten
Well, if you guys are excited, I am really excited, I will say. As you both know, you have been my go-to resources for most things gestational diabetes over the past few years, primarily because ADCES has really kind of taken the step forward in this implementation science space where we're trying to take research, put it into practice, just because we know that's exactly where the diabetes care and education specialist sits.
This is really where you guys sit. You've been emerging stars in this area over the last couple of years. So I'm excited to talk to both of you. And the really cool thing is that we get to talk to both of you together in a conversation. So this is really cool. But before we jump into this topic and hear about all the great work you guys are doing, would love to have you maybe introduce yourself to our audience.
Rachel
Sure. So my name's Rachel Stahl-Salzman and I'm a registered dietitian and diabetes care and education specialist in the division of endocrinology, diabetes and metabolism at Weill Cornell Medicine in New York City. And my passion, as I'm sure many of us here listening and in this room today are passionate about empowering people with diabetes to develop sustainable lifestyle changes and really an interest in leveraging technology and digital health to help improve their health and overall quality of life.
In addition to my clinical care, I hold a couple other responsibilities, including preceptor of our hospital's dietetic internship program, actively involved in interdisciplinary education, and more recently, which will be the focus of today's talk, focused on quality improvement studies to help advance diabetes care.
Kirsten
Fantastic. Kerri, you want to go ahead?
Kerri
Yeah. Thank you again for the opportunity today. I am an associate professor at Bowling Green State University. My training and background, I am a registered dietitian. I've maintained the BCADM credential in diabetes since 2008. And I currently teach in the food and nutrition program and I'm the graduate coordinator. As a faculty member, I have responsibilities related to teaching. I teach medical nutrition therapy, special topics on diabetes, which I love and enjoy getting to do. And then I also do research, and my research has focused primarily on gestational diabetes and diabetes in pregnancy.
Kirsten
Fantastic. And you guys do know each other outside of this, right? Like, I know we've had conversations before.
Rachel
Yes, and it's so exciting to get us in the room together. And I feel like there'll be so many synergies with our research interests. So this is great.
Kirsten
So Rachel, why don't you start with your project? We had a discussion about this. A couple months ago, we were chatting. You were talking about this really cool work you had the opportunity to do at Cornell.
Rachel
Absolutely. So this project on the use of CGM and gestational diabetes was part of a program at Weill Cornell called Quality Improvement Academy. And it was a really unique opportunity, which is a one-year program that trains faculty who are not traditional researchers. We had workshops from leading experts in the field. We learned all the different fundamentals of quality improvement while also working on our own project to benefit the department that we work for.
And for me, it was really exciting because as someone who's dedicated to clinical care, which I find incredibly rewarding, I was really drawn to this program because being able to be part of studies can really help make a broader impact. So when I saw an email about the program, I said, I've got to jump in and try it. And I was excited to be accepted, not only accepted in the program, but also as the first dietitian to attend.
Kirsten
And what was it? This was putting continuous glucose monitors on women in pregnancy, right?
Rachel
Yeah, the focus was really evaluating the use of CGMs in GDM. So we were able to offer it as an option and women were able to choose if they were interested or they wanted to stick to traditional blood glucose monitoring. And those that were interested, we developed a workflow to help support them, educating them through virtual classes on optimizing the use of CGM in pregnancy, because we all know there's specific glucose targets, specific goals that are unique to this population. And as part of the project as well, we wanted to evaluate their experiences. Were they finding it helpful? Was too much data overwhelming? Were there barriers to getting the CGM? We looked at insurance coverage for these devices. So it's really interesting that we were able to evaluate quite a few different areas within this realm.
Kirsten
Any outcomes you could share? Did you see any differences between the two?
Rachel
Yeah. So in terms of our outcomes, one of the big things was just to really evaluate how many women that we offered CGM to were actually interested and able to use it. Were they able to get it through their insurance? Were they continuously using it? Were they stopping it for certain reasons? And we found that over 50%, actually nearly 58% of all participants in our study chose to wear a CGM. And that was really encouraging to us. And while it's great that half of them chose the CGM, we really wanted to evaluate that continued usage. For everyone who's in the CGM world, we know that in order to really evaluate data in a reliable way, we need at least 70% of active time over like a 14-day period. So we chose that as a metric to look at of what percent of them were continuing to use it with that 70% active time. And we found that nearly three quarters of them did wear it for that time. And the satisfaction on CGM was great. We used a glucose monitoring satisfaction survey that was primarily for type two diabetes developed by Dr. Bill Polanoski, and we were able to adapt it for GDM with his guidance. So big thank you to Dr. Polanoski there. And with this survey, it was 15 questions using a five-point Likert scale, ranging from strongly agree to strongly disagree, looking at various factors of CGM satisfaction, such as ease of use, how informative it was to them, was it painful? And we found overall a really high level of satisfaction.
Kirsten
I guess I wonder, like, why not wear a CGM? So you said 75% or three quarters, right? What deters people from wearing a CGM?
Rachel
One of the barriers is insurance coverage. You know these devices, what was exciting and where this kind of research really was inspired was that these devices were approved for use in diabetes and pregnancy, including gestational diabetes in 2022. And the devices are Dexcom's G7, Freestyle Libre 2 and 3. So even though they were FDA approved, the question is, can people actually get it? And we've seen continued barriers, although we're seeing much improvements across different populations, Medicare, commercial coverage. So that was one of the reasons. But also we noticed through our study that there was a lot of lack of health care provider education. This project, we really worked closely with our OB counterparts, educating them about the use of CGM, how to interpret the data, right? To go from four glucose points to 24/7 glucose data, thousands of data points. It could feel very overwhelming. So one of the big barriers was also just HCP support and using CGM.
Kirsten
Well, you know, and that health care provider support is really interesting. It dives into, you know, I’ll mtake a pause here and like switch over to Kerri because Kerri is doing a lot of work in the postpartum realm and really working with DCESs who are supporting women in postpartum. Kerri, do you want to really talk about your work?
Kerri
Yeah, sure. Thank you. And Rachel, that sounds so exciting. I'm excited to hear more about your work.
I was fortunate to work with some members of the Mercy Health St. Vincent Medical Center, which is located in Toledo, Ohio. Their diabetes care and education team and I received a grant from the ADCES Foundation for the project. We were specifically interested in expanding the role of the DCES, specific to the postpartum transition after gestational diabetes. And so within their care system, at the beginning of the project and really prior to the project, the DCES team was engaged during the pregnancy care. They would typically see a patient maybe one to two times and the patient was monitored and managed by maternal fetal medicine. And so we're really looking at how could we expand the role of the DCES and could the DCES act as a bridge between the pregnancy and postpartum period. We felt like the DCES was an appropriate person of the team because they're knowledgeable in diabetes prevention, they have counseling skills, they're an individual that the patient may trust. It really just made sense to really expand that role. One other thing that we did with the project was we used implementation science to really guide the project. So we had some conceptual ideas from the get-go, which included a care planning intervention, again, expanding that role of the DCES. We were focused, though, on using implementation science to better understand how we could create recommendations or best practices and put them into practice. So we know that sometimes there can be that “no-do” or knowledge to practice gap that occurs in translating evidence-based recommendations to practice. So we use implementation science really throughout the process to understand really the factors that affect the adoption, the implementation, and also the sustainability of new practices and care.
We used a multi-level, multi-phase approach. We focused our project over four phases. So we were really meaningful with each of those phases to think about ways that we could make purposeful change within the workflow and also within the system based on the resources that they had available. What I found was really inspiring was that I was asking a lot of the DCES team and they were engaged throughout and using implementation science really provided a flexible approach. They had ideas of maybe what they were getting into at the beginning, but we didn't know every detail from day one. And really that implementation science approach allowed us to explore ways that they could make changes that aligned with the mission of the hospital system, person-centered care, as well as the evidence-based recommendations that were out there related to postpartum risk reduction after gestational diabetes.
Kirsten
Implementation science, it's a topic we talk about a lot but not a lot of people really can truly wrap their heads around it. And you talked about the flexibility and how it can respond to the health system. Can you maybe dive into that a little bit more? Like how is implementation science different? How can it be responsive to the immediate needs?
Kerri
We kind of broke our project into four phases. The first phase was exploration. And within that, we did really a deep dive into what the current practices were within their current diabetes management for gestational diabetes. We really wanted to learn more about what worked, what didn't work. And we engaged stakeholders from within the DCES team, but also the broader system within those conversations. So we had focus groups, in-depth individual interviews. It was a really good opportunity for me as a kind of the outside researcher to learn more about what was going on. But I think it also helped foster some conversations within the team about, you know, what can we do differently?
So, again, there was kind of this idea of a care plan intervention using a DCES, but we use those different phases to kind of move through that. In the preparation phase in particular, we found that we took the idea from concept to really preparing for implementation. There were many moving pieces in this phase and implementation science really helped the team keep moving forward, especially when other demands took over. That was something that was particularly important is that I recall, you know, in the field as a dietitian that sometimes we can have ideas, but the day to day can take over. So my role as the researcher was to really use that implantation science to kind of keep us moving forward. There was some hesitation at different points from the diabetes care team, but they remained excited. They remained engaged. And what really I thought showed through was that they became excited as we kind of neared the end of that preparation phase. And they were really excited about moving into the next steps of implementation. But that preparation phase in particular really helped the team operationalize the care plan and what they would need to do in their workflow to be able to implement something new in their practice. So this included digging into their EHR. They were actually able to develop a template for gestational diabetes patients. And this was a template then that they used throughout the project and it kind of became the standard of care and they're continuing to use that today.
The template, I thought something that was really great was it had pregnancy outcomes and pregnancy data on it, but it also at the same time integrated the postpartum care conversations and care planning. So they weren't using two templates. It was all in one place. And the template aligned with ADCES7. And those were things that really came out of those natural conversations that we had during those exploration focus groups and again the preparation phase meetings as well.
Kirsten
One aside is that you talked about the electronic health record. How was that process working with the team, with your finance and technology team? How did that process work for you to actually make those changes in the electronic health record? Because that's not easy to do.
Kerri
Yeah, I was really happy that the team did it because that was one of the things that we found at the end that was really helpful for them as they were moving into some other conversations that maybe they weren't normally having with patients about risk reduction previously. The electronic health record kind of gave them some talking points and there were some other resources and decision support tools that we developed alongside that that they could have at their desk side. But the EHR change was really driven by the diabetes team. They felt like the template they had before was somewhat maybe superficial and wouldn't be able to capture the care planning elements and they wanted another member of the team to be able to pick the EHR and see what was that conversation that they had about risk reduction and what did the patient decide they want to focus on for post-harm risk reduction. So I think, again, it was really important that the team drove those changes. We did put together some templates. They bounced around a few templates, a few versions about what to keep, what not to keep. Detail is important at the same time there needs to be brevity in the documentation. So I think they found a nice balance in having documentation that was detailed but also something that could be done within their workflow and not take additional time. They also developed an after-visit summary that could be used by the inpatient labor and delivery unit that really reinforced some of the messages on postpartum risk reduction, getting the postpartum glucose tolerance test. And again, these things were really driven by the team. They wanted to think about how can we move this beyond what happens in that one or three or four, you know, touch points that they're having with the patient, right? And they were able to use Epic to create smart phrases and they were able to use that then without having to run into too many barriers, I would say, in terms of getting those things in the EMR. They really drove those changes and they had that ability to do that within their EHR.
Kirsten
Yeah, I think, you know, sometimes we think that it's going to be so difficult, right? Like technology's not going to listen to us. How do we ask these questions? But I mean, sometimes I think it's worth just asking the questions and the diabetes care and education specialists. They're the ones that are subject matter experts in the health system in this area. And, you know, just making those small changes can make such a big impact in people's lives.
Rachel
I feel like we need to adopt something like that Kerri, so great to hear about the research you're doing in postpartum care, because I feel like in so many different health systems, it's often fragmented and limited where, know, we're lucky if they're coming back for their OGTT test. So having the support embedded in the medical record to remind staff of what the best protocol is to support these women is so important.
Kerri
Definitely. And that was something that I'll just add maybe a quick note that came through in our sustainability conversations. We had some focus groups at the end of the project and they would like to automate some of these things in the future so that the after visit summary would be automated when there is an admission and a discharge for gestational diabetes. It would just automatically appear. I think that's a really great opportunity. It again, makes sure that that message gets out there. And then one other thing is also exploring some two-way communication. The DCES team worked with me and we put together these decision aid resources that the patient could use to kind of help them prepare for their visit. But we didn't collect that data and I kind of wish we had, right? That's always one of the things, there's always things you would do differently. But two-way communication in the EHR, I think would also be a great option for this population, especially related to that postpartum care and some of the conversations that they have with patients about reducing their risk. They could kind of share that information with the provider in advance of the visit, or even when they check in that day, it would be helpful.
Kirsten
So quality improvement and implementation science, I love them both because they make change in this system quickly. How do you decide when to use one or the other?
Kerri
So I don't see them as being of one another, but I do see them working together. I think quality improvement can be a methodology that's used for implementation science. That's the way I guess I imagine it. I've had some opportunity to do some quality improvement in the past, and I feel like implementation science is a little bit of a broader umbrella above kind of where QI falls, but it's all focused on making change. Like you said whether you're doing like PDSA or other QI efforts, you're trying to make change in the system. Implementation science is also interested in change, but understanding how the change occurs and what factors might facilitate or hinder that change. So it's not just looking at the change itself or ways to make the change, but understanding maybe within a system or within a particular recommendation, how might that change be best facilitated? So I feel like it kind encapsulates a little bit of many different methods and QI can fall into that.
Rachel
I think Kerri set it up beautifully. That really helped describe the differences and similarities in an eloquent way.
Kirsten
Well, and I think in some ways, both of these are all about getting systems and people within systems and whether you're clinicians or policymakers, practice researchers, it brings everybody to the table to talk. know, especially in this area, I'm wondering how do you see outcomes of your studies? Are there any potentials for collaboration? I see, this is just from a very simplistic view, Rachel, see CGMs on women in pregnancy, Kerri’s work in postpartum. As researchers and clinicians, how do you collaborate and bring your studies together? Or is that ever an opportunity?
Rachel
I think it's a great opportunity. think collaboration is key to help bring research further forward. And for me, in my initial quality improvement project, our goal is to continue data collection, continue to get more people enrolled, continue to reach out. I mean, even within our institution, there are so many different OB practices where we get referrals for gestational diabetes. So even within our own practice setting, but then collaborating with other clinicians at other institutions would only help to further understand and bring more data to help with statistical significance to help make a broader impact.
Kerri
I agree. And one other, I guess, thing I would add would also be related to implementation science that I kind of saw with this project in particular. It allowed the DCES team to engage with other stakeholders that maybe they didn't engage with on a day-to-day basis. When we had some of our conversations about care and some of the resources that women have, but also some of the barriers that they experienced, barriers related to social determinants of health, for example, came up. And we were interested in looking at this from that health equity lens. We wanted to make sure that the DCES team had access to maybe resources that they could help connect patients to who had gestational diabetes. You know, in terms of if they were talking about healthy eating, do they need access to food? Right. So how do we make that connection? So one thing that we did with the implementation science process is we also engaged some of those external stakeholders.
And that was a great thing that happened that maybe wasn't quite planned from the beginning, but those conversations and meetings that we had really demonstrated that we needed to do that. So I think that's another great thing that can happen in terms of collaboration is also thinking about outside of the DCES, who can we work with?
Rachel
And I would also add, a big takeaway in terms of how we can broaden the impact was that the quality improvement study that I focused on was a lot about virtual care. We offered virtual classes teaching women about what gestational diabetes is, the foundation of lifestyle management, and then a special class dedicated solely to CGM. And what we found was that people find these convenient. They've already got enough in-person pregnancy appointments to go to. You know, people are embracing the virtual care model, which we've seen, of course, tremendously increase since the COVID pandemic. So I think that for us, a big takeaway was learning that telehealth is here to stay. And it's been an opportunity to not only overcome geographical barriers, but ensure more people receive the support. We're able to see more people in that one hour than having individual appointments, which in a busy endocrine practice can be unrealistic in a lot of ways. So that also combined with the peer support of a group class in a virtual care setting was also a big takeaway.
Kerri
I didn't realize that your project also had telehealth. So we did telehealth as well. And that was an option that a lot of patients really did, I agree, it was well received. It was accepted. They did the postpartum touch point with patients that was done through telehealth. And it was a way to connect with women in that postpartum transition that made it more feasible. And I think that is something for this population in particular they valued. And it's interesting to hear that you had a similar outcome as well.
Kirsten
Well, I can jump in and say that I'm a mom of two. And in pregnancy and post pregnancy, that period of time right after is a crazy time. So anything you can do to make it easier on women, I'm sure they're grateful. Any final thoughts you want to share, any empowering thoughts you want to share with the DCESs that might be listening?
Rachel
Absolutely. You know, a big takeaway from the quality improvement study that I did is that, you know, we see the power of technology to empower people with gestational diabetes. You know, we saw that it led to greater satisfaction, more confident in their management plan. And at the core of it is the important role of the CDCES to provide that necessary education and support to help people interpret the data, troubleshoot challenges, ultimately maximize the benefits of the CGM technology. So my big call out is that CDCESs can be leaders in integrating technology into the various populations to really support a person-centered approach, helping improve health outcomes. And it's definitely a team effort. I think as we've seen with all of this, takes a team, it takes a village to help see everything come to fruition. So I think making sure to keep the team motivated, keeping everyone with that shared vision could be really important to your projects and research interests through.
Kerri
And I would just add that I truly enjoyed the opportunity to work with the diabetes care team. And I believe in what we can do. And our project really, again, just reinforced that the diabetes care team is an integral part of the health care team. You know, thinking about whether it's trying to integrate CGM or any new practice into our workflow, it's important that we give ourselves permission, right? And I think the implementation science approach, for at least our project, helped that DCES team not feel boxed in. And I would just encourage others who are interested in trying to implement a new practice or a new standard of care to do that. And again, perhaps use implementation science. There are a variety of frameworks and approaches out there. And there's a lot of great resources that you can use to help foster that change. The DCES team while they were focused on patient outcomes, there were some really great outcomes related to the clinician side. And implementation science is not just focused on the patient, but also the clinician and the health care system. And what they were able to see is that they could reframe their role. It had provided some job enrichment. They were able to stay with that patient beyond the pregnancy period. And it was well received and well-recepted by stakeholders, patients. It opened doors for future research, which was super exciting. They've had recognition from their leadership. So I just would encourage you to think about how can I push myself out of the comfort zone? And maybe this is something that I can use to do that and to engage others who can help me do that.
Kirsten
Well, this conversation has been incredible. And what I heard at the end here was the system might be a maze, but diabetes care and education specialists can give themselves the permission to be leaders. And that's what I'm hearing from both of you, right? As I synthesize your last thoughts, it's give yourself that permission to be a leader because that's really what's gonna make the change for the patients that you're supporting. Kerri and Rachel, thank you so much for this conversation. I know you both have resources that we're gonna put in the resource links for this podcast that people can access. I'm sure people will wanna reach out and talk to you. But again, grateful you were here. Thank you so much for this conversation. I always have fun talking with you.
Kerri
Thank you. And just a plug, I will have a poster at ADCES. If anybody wants to stop by, I'd be happy to share more information about our project and what we found.
Rachel
And I'll also be at ADCES and presenting on this topic. So definitely, we look forward to meeting you.
Kirsten
Well, I'm going to stop by and see both of you at ADCES in New Orleans. That's going to be fantastic.
Kerri
Thank you.
Rachel
Thank you so much.
Kirsten
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes. And remember, being an ADCES member gives you access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at adces.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.