JOINT BASE SAN ANTONIO-FORT SAM HOUSTON, Texas, (March 19, 2021) -- The Diabetes Remote Electronic Assisted Monitoring, or DREAM, program focuses on teaching patients how to measure and adjust their insulin independently based on their provider’s instructions.
A team from the Military Health System Virtual Medical Center worked with the Diabetes Center of Excellence at Wilford Hall Ambulatory Surgical Center to develop a program to help augment a patient’s diabetes treatment plan, providing support to the patient between provider appointments. The program is available for patients and providers across the San Antonio Military Healthcare System.
“The main idea was that patients are often told to titrate (go up or down) on their basal insulin based on a pattern of fasting glucoses,” explained Air Force Maj. Darrick Beckman, endocrinologist and Diabetes Center of Excellence medical director. “However, it is not uncommon for patients to be overwhelmed at appointments. And, even with having written handouts on how to titrate their insulin, when they return in three months, there have been no adjustments made to their insulin and their diabetes is not better controlled.”
The DREAM program offers patients help from a registered nurse to review their blood sugars and to help them identify patterns related to lifestyle that may impact their blood glucose levels. Patients also learn how to titrate their basal insulin according to the appropriate protocol as ordered by their provider.
After a provider refers a patient to the DREAM program, a registered nurse will contact them by phone to make sure they are suitable for the program and willing to participate.
“From there we set up an orientation to walk them through the program plan, including diabetes education,” said Nichole Carreon, one of the two DREAM registered nurses. “Each week we have remote encounters by telephone to go through their weekly glucose readings and help them with their basal insulin through a titration protocol. The goal is to get patients into their prescribed target range for four weeks or titrating independently on their own for six weeks before we consider graduation from the program.”
Beckman said they worked hard to develop the algorithm(s) and the overall referral process to ensure the appropriate information is transmitted from start to finish -- from provider referral and monthly reports to graduation from the program.
“We beta tested products and reports with primary care managers to get feedback about what data they would desire and even how often they would want reports,” he said. “We had to ensure continuity of care for transitioning providers. Once the patient was referred, we wanted there to be clarity to the providers about how the patient was doing and the ability to notify of acute concerns from nursing, in as little time as possible.”
Once the patient is appropriately educated and feels comfortable to titrate on their own, they no longer need the program, Beckman explained. “This titration capability is something the patient can use life-long.”
Since DREAM launched in February 2019, they have had more than 60 participants go through the program.
“It has taken on average about 5.1 months for participants to complete the program and we have seen an average A1C improvement of up to 2.5 points,” said Kim Wasmuth, DREAM RN. “Most patients reach their target goals before the end of the program and/or are able to titrate their basal insulin on their own. For those who do not reach their target goal, they leave with the tools needed to adjust their insulin on their own so that achievement of their goal is much more likely than without those tools.”
Beckman said from a provider perspective the DREAM program works well.
“I can make quicker adjustments in insulin, with little time spent on the overall process,” he said. “And, acute issues can be identified, such as hypoglycemia, and I can intervene quicker.”
“Patients tell me they enjoy having an accountability partner,” Beckman added. “They say that they’re more likely to remember to take their insulin doses because they know they need to report the numbers to the nurse.”