Taking a Team Approach to Treating Pedorthic Patients with Diabetes

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By Howard Hillman, CPed
elderly woman with caregiver

On a Tuesday morning some months ago, one of my long-term patients arrived with a bag of shoes in one hand, her quad walking cane over her other arm, and her caregiver trying to keep up with her. I really never saw her use the cane, and I had wondered if it might have been her idea of a self-defense weapon rather than an assistive device. As soon as I saw her face, her chart notes came to mind: "Seventy-five-year-old female, type II diabetic with a history of callusing and several occasions of wounds leading to a transmetatarsal amputation of the right foot." As we caught up on what was new in her life and filled out the appropriate paperwork, she introduced me to her new caregiver. I asked the caregiver if she had anything to add regarding her patient's health. She replied that she didn't.

I then began by removing my patient's left shoe to examine what had always been her healthy foot. Once her shoe was off, I could see a quarter-size bloodstain on her white sock, at which point I asked how long she'd had a wound on her foot. She replied, "Oh, not long. Maybe a week or so." Her caregiver said that she had not seen the wound and confessed that she was really just the driver since my patient was very independent.

I excused myself from the room and called the woman's podiatrist to be a tattletale. Back in the patient room, I informed my patient that the podiatrist wanted to see her today and would have an assistant meet her at the door of the medical building with a wheelchair in 30 minutes. She was not happy about having to change her schedule and stated that it would have to wait for another day. "I'll be fine," she said. Her caregiver agreed that they did have a busy day but probably could make an appointment for later in the week. While they discussed it, I removed the patient's right shoe to examine that foot. This gave me the opportunity to say, "This foot had a wound as well at one time...." I went on to tell her that the podiatrist had said to call an ambulance if needed. The pair hesitated but agreed to put their other plans on hold and head to the medical building.

After seeing her podiatrist and after her wound had healed, she came back to see me for what we had planned to do at her prior appointment-examine her feet, cast for a new partial foot filler for her right foot, cast her still intact left foot for a custom, full-contact offloading device to prevent future ulcers, and order an appropriate pair of therapeutic shoes. A couple of weeks later, her shoes and devices were ready and were dispensed without a hitch. She then thanked me for being so insistent about seeing her podiatrist.

Today's ever-increasing incidence of diabetes presents a great challenge to the pedorthic profession-a challenge that, if statistics prove to be true, may well seem like an insurmountable battle. With the rising cost of healthcare and unforeseen changes in coding and compliance issues, there are more moving parts than ever. However, if pedorthists are to provide the level of care that our patients deserve, we must look for the new opportunities that each day brings. We've gone from a time when patient compliance with extra-depth shoes seemed impossible to having a vast array of vendors and styles from which the patient and the practitioner can choose to get the most positive patient outcome possible.

We have studies that prove what we always knew about the efficacy of appropriate footwear, braces, and offloading devices to aid in wound healing and prevent falls, as well as the role pedorthists can play in their patients' overall healthcare. We can offer quantifiable plans from a position of strength and knowledge to our patients and their caregivers. By working together with your referring physicians and physical therapists, simple but effective protocols can be put into place. If you feel your patient is at risk of falling, a note to the referring physician discussing your treatment and observations of this patient might include a sentence stating that you think that he or she may be a good candidate for a fall risk assessment. Communication between healthcare providers is imperative to achieve the best possible patient outcomes. Remember the patient who I spoke about earlier, how she hung her cane over her arm instead of using it as an assistive device? When I saw her for a follow-up appointment she was using her cane, so I asked her when she started actually using it rather than carrying it around with her. She responded that "a nice lady at the doctor's office showed me how to use it properly and adjusted it for me." It was something I could have done if I'd thought about it, but I was delighted that the "nice lady" had taken the time.

We have this great pool of knowledge and depth of concern that helps us serve our patients' needs on several fronts. Whether it be working in concert with a wound healing specialist to save the foot of a patient with diabetes or knowing where to send a patient who is seeking dietary advice. By interviewing your patients, you will gain a wealth of knowledge. For example, ask the patient who has lost 75 pounds how he or she did it, who helped, and what he or she is doing to keep the weight off. In one such situation, I contacted the physician who had assisted the patient during weight loss and kept his card as a handy resource for my other patients. Don't be afraid to talk to your patients about topics such as fall prevention. Bring up the topic while talking about shoes and shoe design. Compile a quick fall prevention checklist by visiting the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov

Remind patients with diabetes and their caregivers to check for wounds.

In putting together any action plan, getting the patient and his or her family onboard with the plan is essential. Make sure to give them the resources and help to get started.

Many times patients will give you the opportunity to speak openly and frankly about their disease, and because of what we see in our daily practice, we are well equipped to speak honestly and caringly. Don't be afraid to discuss what happens to the noncompliant patient with diabetes. Give patients good reasons, backed with facts and experience, and offer caring solutions that fit the patient's situation. A patient with diabetes complicated by excess weight once told me that all he wanted to do was live long enough to see his granddaughter graduate from high school. So I asked him, "Isn't she going to college?" He smiled and said, "Well, I guess I'll want to stick around for that." To which I replied, "Let me give you the name of a guy that can help you with your diet." Next time this patient came to see me he had lost 50 pounds and said he felt great.

We often hear the term "appropriateness of care." But by putting forth the extra effort to develop team approaches with our patients, their referring physicians, and caregivers, we'll continue to hear that what we offer is "appropriateness of caring."

Howard Hillman, CPed, is currently president of Signature Custom Orthotics Lab, Brighton, Colorado.