Innovative Diabetes Care and Education Services to Improve Outcomes in Youth-Onset Type 2 Diabetes

Type 2 Comprehensive Clinic

Due to the increasing incidence of young people with T2D and the expanding therapy options, the pediatric diabetes team with the University of Oklahoma Health formally established a Type 2 Comprehensive Clinic (T2CC) in 2018. The clinic includes interdisciplinary care and comprehensive services available with 2 board-certified pediatric endocrinologists, an advanced practice provider, a pediatric psychologist, and a rotation of 2 to 4 CDCESs and DCESs. Services are rendered to pediatric patients with a wide payer mix, including Medicaid, Medicare, other government-managed programs, commercial, private, and self-pay. The clinic was intentionally designed to provide same-day expert services, embrace new and innovative therapies and education, and address the psychological implications of T2D in young people. The in-person clinic is held twice monthly in the ambulatory clinic space. Quarterly T2CC staff meetings are held to ensure necessary and ongoing standard of care updates, best practices, and collaborations as needed.

Population Challenges

The T2CC team identified medication-taking behaviors inconsistent with treatment plans when patients returned for follow-up. Specifically, patients reported insurance issues, pharmacy back orders, or negative side effects or experienced other complex psychosocial environmental factors resulting in delayed titration to therapeutic dosage or missed medications entirely. This was found most common with GLP-1 RA but also affected patient metformin and insulin goals. In accordance with common national models for interdisciplinary pediatric diabetes teams, patients had access to the team in between office visits that included usual business hour communications and 24/7 emergency contact. However, many families did not contact the team to problem-solve in between T2CC appointments. SDoH and other disparities may have impacted family efforts between appointments, and the team determined to increase DCES contact for earlier assessment and opportunity to address barriers to medication-taking behaviors.

Titration Clinic

A Titration Clinic was designed and implemented in 2024 to address T2CC population challenges with increased DCES contact for patients prescribed GLP-1 RA and other medications that required dose titration, such as metformin and insulin. DCESs were an integral part of planning, and clinic sessions were managed by team registered dietitians and nurses. Titration Clinic referrals were placed by the provider for patients seen in T2CC and started on medication therapy for additional family education and support between provider visits with an emphasis on problem-solving. The clinic was held 2 full days per month and scheduled as virtual visits to reduce any socioeconomic barriers, although appointments were available in person on request. The presence of both the patient and legal guardian was required to complete the visit. However, if the patient was unavailable, then assessment of needs was still completed via phone call with the legal guardian, and the Titration Clinic appointment was rescheduled. Irrespective of automated appointment reminders, Titration Clinic appointments were sometimes no-showed or canceled at the last minute. Nevertheless, the scheduled opportunity provided additional contact with legal guardian(s) for discussion and similar problem-solving support to aid in titration goals.

The ADCES7 provided framework for our diabetes self-management education and support services. ¹² Titration Clinic appointments with the DCES prioritized patient assessment and family discussions focused on identifying barriers and involved the ADCES7 Self-Care Behaviors: healthy coping, healthy eating, being active, taking medication, monitoring, reducing risks, and problem-solving. The knowledge and practiced skill sets of a DCES with the CDCES and/or board certified-advanced diabetes management certification(s) provide an advantage in this advanced practice setting. Additionally, the ability for the DCES to quickly pivot within the clinic visit requires close team communications and established guidance for the DCES to ensure necessary referrals, provider orders, and practice within the individual’s scope.

Program supplemental patient materials for T2D was incorporated as needed for specific medications, nutrition, and other lifestyle considerations to limit side effects with GLP-1 RA or support other individualized therapy goals. Goal setting played a critical role in patient behavior changes, and the DCES facilitated goal-setting conversations so that patient goals were intentionally specific, measurable, attainable, realistic, and time-specific (SMART). Anthropometric data, A1C, lipids, blood pressure, and other labs were routinely monitored during T2CC for additional outcome data.

Clinic visits involved problem-solving medication access, medication tolerance, glucose data, dose adjustments as guided by provider plans, nutrition, activity, and related SMART goals. Real-time efforts included actions to address pharmacy or insurance issues and provider communications to determine next steps or modified therapies. Patient scenarios included patients taking medications without implementation of recommended dietary changes, and nutrition assessment was essential to guide plans for any overconsumption or underconsumption of dietary needs and recommendations for any side effects common to GLP-1 RA. Return appointments were scheduled in the Titration Clinic if therapeutic doses were not yet established before the next scheduled follow-up in T2CC. Diabetes team members have called the clinic a “one-stop shop” for the patient’s diabetes care needs. Although not a comprehensive list, visit objectives included (1) addressed pharmacy issues and confirmed prescription pickup to initiate GLP-1 RA therapy; (2) titrated GLP-1 RA, metformin, or insulin medications to therapeutic goals; (3) titrated medications down or weaned off insulin therapy following T2D diagnosis; (4) developed dietary goals to meet nutritional needs and manage therapy side effects for continued therapy; (5) instituted therapy change and educated on a new GLP-1 RA; and (6) initiated continuous glucose monitoring system to provide insight into glucose trends. A checklist for a diabetes team to consider if planning a similar titration clinic is found in Table 1.

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Table 1

Titration Clinic Checklist

Service assessment • Demand, volume, and capacity

Stakeholders • Recommend a multidisciplinary team as part of planning, implementation, and ongoing feedback, edits, and updates • DCES with practices approved by a MD and guided by the DCES competencies 10 • Referral base

Planning • Clinic design • Scheduling template(s) and process • Referral process: must include documentation of medication type, doses, and detailed titration goals • Titration protocol or guidance (organization, department, services, and/or medical director approved) • Resources  ♦ GLP-1 RA consensus recommendations 11 and other evidence-based resources to guide recommendations  ♦ Determine or develop patient materials • Communication routines for timely and efficient provider updates and new recommendations as needed  ♦ Plan if medication not covered/affordable, medication intolerance despite usual recommendations, or another insurmountable barrier • Documentation  ♦ Check-in paperwork • Electronic health record (EHR) templates, flow sheets, or smart tools

Clinical implementation • Documentation • Billing G0108, others considered as needed • Communication  ♦ Referring provider and other team members as needed  ♦ Patient care summary and additional follow-up needs • Process for ongoing feedback and edits to improve efficiency or processes as needed • Best practice updates and incorporate new medications when applicable

Abbreviations: DCES, diabetes care and education specialist; GLP-1 RA, glucagon-like peptide-1 receptor agonist.

Results

Data evaluated so far indicates that 76% (N = 85) of scheduled Titration Clinic appointments in 2024 and 77% (N = 120) in 2025 resulted in either visit completion or phone contact with the legal guardian. The T2CC team found problem-solving with DCES in between formal T2CC clinic visits improved medication-taking behaviors and allowed more effective time spent during follow-up visits. When asked for comment, a board-certified pediatric endocrinologist who helps lead T2CC said, “The focused effort of the DCES in Titration Clinic on goal setting to ensure medication taking and alleviate GLP-1 RA side effects to achieve dose escalation has provided significant benefits to both providers and patients. Observed dose titration between T2CC visits has dramatically reduced the A1C in the group of patients that consistently attends Titration Clinic.” Such comments and other collective feedback have demonstrated Titration Clinic to be a successful addition to current services. Next steps include assessment of objective patient metrics and outcome data to evaluate clinic effectiveness and identify opportunities for improvement.

Summary

Current diabetes treatment options may require additional education and problem-solving for successful implementation of the diabetes care plan. DCESs can empower patients with essential education and skills to help navigate the complexities surrounding pharmacy, insurance, and the unmet social needs that might limit family problem-solving. With growing therapy options in T2D and the expanding indications of medications to include comorbidities beyond diabetes and obesity, there may be additional patient education and support needs. Our Titration Clinic models innovative opportunities for DCESs to use novel educational modalities to increase patient knowledge and understanding and improve outcomes. ■