Rising to the Occasion: How Challenges Unleashed by COVID-19 Will Improve Diabetes Care for Years to Come

February 10, 2021

photo of diabetes educational resource on St. Michael's Hospital patient portal

It’s no understatement to say 2020 was a year of upheaval, with practically no aspect of life—or healthcare—untouched by the COVID-19 pandemic. Diabetes care, which relies on a high level of cooperation and coordination between patients and multidisciplinary teams of care providers, has been no exception.

“We have spent the last five years working to improve upon a collaborative chronic disease model of diabetes care,” says Dr. Phillip Segal, Medical Director of the Diabetes Program at the University Health Network and Chair of the QUEST Committee at the University of Toronto’s Banting & Best Diabetes Centre. “We perfected multidisciplinary in-person visits with many different professionals and the patient in the same room. We spent money retrofitting our education rooms.”

But when the pandemic hit in March, Dr. Segal says, “all that stopped overnight.”

Across the Greater Toronto Area (GTA), Ontario, Canada—the world—mainstays of patient care had to be put on pause. “The hospital was prohibiting us from having patients come to the clinic,” Dr. Segal recalls. “Moreover, patients were too afraid to even go to the lab to do their blood tests.”

But with these once-in-a-lifetime challenges have come new opportunities, as the pandemic forced clinics to re-envision all aspects of diabetes care. Some of those obstacles remain ongoing. But in many cases, the creative and innovative tactics clinics had to employ will create lasting improvements to patient care that will persist long beyond the pandemic.

Pivoting to Virtual Care

In the early days of the pandemic, a deal between the Ontario Medical Association and the Ministry of Health unlocked the ability to provide telehealth services to patients. But diabetes clinics were ill-prepared to instantly turn on virtual care, necessitating a rush to enable new tools and workflows.

University Health Network (UHN) rapidly invested in equipping every room in the clinic with video capabilities. At the same time, UNH Digital was engaged to create new electronic templates that would replace paper charts and improve communication between all members of the team. At the Centre for Diabetes and Endocrinology at St. Michael’s Hospital, a new patient portal became a go-to resource, housing step-by-step guides for insulin pumps and glucose monitors, along with appointment reminders. (Moving forward, the team hopes to expand the portal to facilitate workflows such as consent for email communication and COVID screening.)

Learning to work with these new tools wasn’t always easy. “There was definitely a learning curve,” says Elizabeth Jung, an advanced practice nurse at Sunnybrook’s Diabetes in Pregnancy program. “Some team members were more tech savvy and found learning new technologies easy and quick and more efficient, whereas those who were less tech savvy experienced a more difficult and bigger burden.”

But as staff grasped new technologies, they, in turn, helped their colleagues to learn and adapt. “The clinic constantly evolved until a balance and a ‘new normal’ was found. We’ve been running very smoothly for many months now,” says Jung.

Striking a Balance Between Online and In-person

Part of the delicate dance of providing diabetes care in a pandemic was not only determining what could be handled virtually but also identifying when virtual care would not be appropriate. Sometimes—such as when blood sugars become dangerously high—patients must be seen in person. For such acute instances, Mount Sinai Hospital and UHN quickly partnered on an urgent diabetes clinic, allowing for faster referrals for patients who needed to be seen in person.

For those who did need to come in, appointments created new logistical challenges—for example, coordinating patient drop-offs and pick-ups because family members and caregivers could no longer access waiting rooms. At the Centre for Integrated Diabetes Care at Women’s College Hospital, staff members were frequently dispatched to a hospital entrance to hand over medications and supplies.

But whenever possible, clinics pulled out all the stops to support patients without requiring them to come in.

Women’s College Hospital tapped into video tutorials and other educational resources from all available channels—QUEST, blood sugar meter and insulin companies—giving patients an arsenal of information to ensure the virtual continuity of care. Across clinics, everything from insulin start and pump program classes to Sunnybrook’s pregnancy support and learning groups were transformed into regular online sessions.

Ongoing improvements to care delivery are still underway. For example, some patients lack the computer access or know-how to download their own sensor data—a problem that, nearly a year into the pandemic, still has no easy workaround,—but Mount Sinai is working on a tool to provide clinicians with this vital information.

Photo of new diabetes Instagram account launched by St. Michael’s Hospital

“Lots and Lots of Plain Hard Work”

The pivot to virtual care, however, has required more than plugging in new technology and learning to use it. The shift to online delivery has created new workflow and administrative burdens on clinic staff, exhausting providers and support staff and increasing their risk of burnout. At St. Michael’s, the problem was compounded as diabetes clinic staff were reassigned to the hospital’s COVID assessment centre.

“Though we are not on the front lines, we are much busier than before performing tasks that may not  be designed to be done over the phone,” says Dr. Segal. “It’s been lots and lots of plain hard work.”

“Workflow has had to change to accommodate more requests by email, and most of our team has found a need to set aside time to respond to email questions or concerns, especially with our T1 population (with Type 1 diabetes),” says Danielle Goudge, a certified diabetes educator at St. Michael’s. With patients unused to virtual appointments, Goudge says, they required more scheduling reminders. “Many patients do not value or are not respectful of the time for the scheduled appointment. Some patients feel that since it is just over the phone it is not a ‘real appointment,’” says Leah Drazek, an advanced practice nurse in the Endocrinology department at Women’s College.

To that effect, Mount Sinai went as far as to develop virtual etiquette modules that have become part of the consent process prior to attending group sessions.

A New Era of Care and Collaboration

Despite all these challenges, clinics say they continue to increase efficiency. Even better, new processes, best practices, and tools adopted during the pandemic will likely lead to lasting improvements and innovation in diabetes care.

At Mount Sinai, the team’s work developing indicators to help evaluate the safety, effectiveness and efficiency of virtual insulin start groups for GDM patients earned a QI innovation award. Meanwhile, other clinics have recognized the value of virtual access in improving compliance for certain groups. “We have moved to make video visits a default for the young adult diabetes clinic. Our no-show rates for the young adult clinic have dropped during the pandemic,” says Dr. Eleni Dimaraki at Women’s College.

The need to replace in-person visits with new touchpoints has also encouraged new levels of creativity and experimentation. At St. Michael’s this included launching the clinic’s first Instagram account. “As a team, we wanted to ensure that patients felt like they could maintain ongoing communication and a sense of connection with the clinic despite limited in-person interactions, especially if they had never met us before,” says Goudge. “Through this account, we have been able to introduce community members to our staff, offer quick educational tips on how to prepare for virtual visits, and provide up-to-date information on COVID-19 and diabetes.”

Improvements born from necessity—but that will provide benefits for people with diabetes, their families, and healthcare providers, even once the pandemic is long behind us.

(We are grateful to individuals at the following hospital sites for their contributions to this article: Mount Sinai Hospital, St. Michael’s Hospital, Sunnybrook Health Sciences Centre, University Health Network, and Women’s College Hospital.)