Diabetic Foot Care is All About the Experience

Diabetic Foot Care is All About the Experience 1

The Comprehensive Diabetic Foot Experience (CDFE) 2

The Comprehensive Diabetic Foot Experience (CDFE) 3

The Comprehensive Diabetic Foot Experience (CDFE) 4

The Comprehensive Diabetic Foot Experience (CDFE) 5

The Comprehensive Diabetic Foot Experience (CDFE) 6

The Comprehensive Diabetic Foot Experience (CDFE) 7

The Comprehensive Diabetic Foot Experience (CDFE) CMS says you can’t put the same shoe on every foot 8

The Comprehensive Diabetic Foot Experience (CDFE) 9

The Comprehensive Diabetic Foot Experience (CDFE) 10

The Comprehensive Diabetic Foot Experience (CDFE) 11

So… § If a patient can’t see or feel their symptoms, they won’t acknowledge they exist… o Those that have lost the “gift of pain” are at highest risk for developing diabetic foot complications § If you can’t find your high-risk patients, you can’t effectively treat them… o You must prevent complications before they appearonce they appear, its too late § Effective patient education is essential for meaningful preventive care results… o If they can’t understand why they are at risk, how can you educate them about solutions like therapeutic footwear? 12

How do we do a better job of educating our diabetic population? • Educate your staff on the importance of a podiatrist’s role in preventative care (do they really understand? ) • Provide a higher level of care to your patients by going above and beyond dispensing shoes • Teach your patients how to stay actively involved in their personalized care plans. • Utilize your team to assist in improving the patient experience • Start rethinking your CDFEs as an opportunity rather than a chore • Document, Document • Don’t lose track of your diabetic patients 13

Defining the CDFE from the 61 day visit • Common question, can I do a CDFE during the “regular” visit? • The answer is you can, but you shouldn’t • Not enough time is allotted during your Routine Foot Care visit to provide an actual COMPREHENSIVE Diabetic Foot Exam • If you combine these visits, you are not relaying the importance of this separate exam and opportunity to educate and prevent future complications 14

A true CDFE consists of evaluation, documentation and plan of management according to risk findings and include. . . • Vascular compromise • Neurologic compromise • Non-traumatic amputation of foot or integral skeleton portion • Absent posterior tibial or dorsalis pedis pulses • Advanced trophic changes • • • Decrease or absence of hair growth Thickening of nails (nail changes) Pigmentary changes (discoloration) Thin or shiny skin texture Rubor or redness (skin color) Claudication Temperature Changes Edema Paresthesia 15

To provide the true experience we should include. . . • Temp Stat, Pressure Stat and Derm Stat exams • Showing temperature differences, high pressure areas of the foot that can suggest break down of skin/ulceration without proper support and insufficient moisture levels • These serve as valuable educational tools for your patients and allow them to SEE what is going on in areas they usually don’t • They also provide us with definitive proof of our findings for documentation and future management/measurement of prevention and treatment. • Diabetic foot care and prevention educational brochures • Your patients should feel as if they learned something during the visit and leave with a renewed sense of the DPMs role in their preventative care. (And they thought you only cut toenails) 16

Recommendations/Needs based on your findings • Need for Therapeutic shoes and custom or pre-fabricated inserts • Vascular testing • Compression stockings • Anti-fungal treatments for skin/nails/shoes • Urea based creams/emollients for severely callused skin or nails • Diabetic safe lotions/moisturizers for daily use • If Neuropathic symptoms are noted: • Schedule for small fiber biopsy • In-Office dispensed supplement 17

Next Steps: Measure the patient for the appropriate style/size/width and. . . Begin the dreaded shoe paperwork! 18

7 Required Documents for Diabetic Shoes Prescription (RX) written by DPM (prescriber) Detailed Written Order (by DPM) Statement of Therapeutic Necessity - Signed by MD/DO Supplier in person evaluation, CDFE Note (performed by DPM)** Relevant Medical Records- Signed by MD/DO Dispensing SOAP Note- Signed by DPM(supplier) (important to include size, make, model and width Patient Acknowledgement Form/Proof of Delivery Signed by Patient and Witnessed by staff

The Rx Rx: Therapeutic/Extra Depth Shoes Patient: [Patient. Name] DOB: [Patient. Birthdate] Date: [Date] Quantity, Product and HCPC Codes 1 pair Extra Depth Shoes (A 5500) to prevent infection and ulceration (3 pair) (A 5512) direct formed and molded to foot with external heat source (i. e. heat gun) prefabricated multiple density inserts Diagnosis: Diabetes type II with history of peripheral neuropathy with evidence of callous formation, foot deformity, poor circulation, as evident by [? ? ]. Theraputic Objectives: Prevent pedal ulceration, Facilitate gait, Maximally distribute plantar pressure Duration of Usage: 12 months Prescriber: [Provider Name] NPI: [Provider NPI] 20

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The 30 Supplier Standards form • This has to be offered to your patients (prior to 2016 it had to be provided). Few will want it, but you should have a copy displayed for your patients and your should be aware of what it says. • Update your dispensing chart notes to reflect this change. • For example: “Written instructions, warranty information, and proof of delivery/patient acknowledgment form was provided and the patient was offered a copy of the DMEPOS 30 Supplier Standards. All questions were answered. ” • AND remember hours need to be posted outside the office. 24

In conclusion. . . • The CDFE is not just about shoes it’s about the experience and education we are providing our patients. • Podiatrists are on the front lines of defense towards preventing diabetic complications. • CDFE does not = shoes but consider this: • It costs Medicare less to pay for shoes/inserts for all of the qualifying diabetics in your practice than it does for just one amputation. • Are you capturing all (okay, most) of the qualifying diabetics in your practice? 25