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Diabetes Nurse Practitioners

By Jane Jeffrie Seley, GNP, MPH, MSN, CDE, and Marie K. Medenilla, RN, BSN

Last Update: July 2, 2003

During the course of your life with diabetes, you may see many specialists, such as endocrinologists, dietitians, foot doctors, and family counselors.

Is a diabetes nurse practitioner right for you?

But if your regular doctor is having difficulty helping you control your diabetes—say you're unable to get your A1C to 7 or below—you may be referred to a nurse practitioner (NP) who specializes in diabetes. Nurse practitioners can help you get a grip on the practical issues of diabetes control.

You also need a constant in your diabetes life: the generalist you see for your regular check-ups; the health care provider you call when your fever is 103°F and you can't keep any food down.

“What is a Nurse Practitioner?”
A nurse practitioners is a registered nurse who has advanced training and clinical experience. Nurse practitioners take advanced course work in pharmacology (how drugs affect the body), pathophysiology (disease states) and health assessment.

Before going into practice, nurse practitioners must log a minimum of 500 supervised hours working with patients.

The nurse practitioner role originated to provide primary care to underserved populations in nontraditional health care settings such as schools, work sites, and health departments. But nurse practitioners now serve a wide variety of patients in specialty areas such as diabetes. They also serve in diverse practice settings including group practices, hospitals, and health maintenance organizations.

When a diabetes nurse practitioner works in a primary care private practice or clinic, he or she serves as the diabetes expert in that practice. Primary care doctors will refer their patients who are having difficulty controlling their diabetes to the diabetes nurse practitioner. In an endocrinology practice, the diabetes nurse practitioner focuses on medical management and educating patients on skills and knowledge needed to live with diabetes.

Diabetes nurse practitioners differ from diabetes educators in that they have different training requirements and can legally prescribe and adjust medications. The scope of practice for nurse practitioners, however, varies from state to state. Most states allow nurse practitioners to prescribe medication with little or no physician supervision.

“Will My Insurance Company Cover My Visits With A Nurse Practitioner?”
Before 1997, most nurse practitioners were reimbursed only for medical care provided to underserved people, primarily at pediatric and family primary care facilities in rural areas. Today, both Medicare and Medicaid allow nurse practitioners to be paid directly for their services.

Many insurance companies do not accept nurse practitioners as providers in their plans, and this limits reimbursement. But practitioners can sometimes get reimbursed for services provided under out-of-network provisions in some policies. You may also be able to use a flexible spending account, which uses pre-tax dollars to cover medical costs that are not reimbursed by a particular plan, to pay for such services. If you have a choice of insurance plan, you may want to ask whether the policy offers coverage for diabetes nurse practitioners; also be sure to check to see if it covers equipment, including blood sugar checking supplies and insulin pens.

“Should I Choose A Nurse Practitioner Over A Doctor For My Regular Care?”
If you feel you need more emotional support than your doctor has been able to give you, you may want to see a nurse practitioner. In a busy primary care practice, doctors sometimes don't have as much time as they would like to spend with you. A diabetes nurse practitioner can provide one-stop shopping: medical management, health counseling, and skills training. This multifaceted expertise helps nurse practitioners motivate people with diabetes to make difficult lifestyle adjustments. Here's an example:

Barbara, 45, was referred to our practice by her primary care doctor. Barbara had had type 2 diabetes for a number of years. Her A1C results showed that her average blood sugars for the past two or three months were in the 300s, which is dangerously high. But she refused to take medication or check her blood sugars, as her doctor recommended. She feared the side effects of the medication and didn't want the discomfort of fingersticks.

It was clear that Barbara needed emotional support to overcome her fears, so we first focused on non-threatening information such meal planning and basic diabetes education. Of course, we were also eager to get her started on medication as well, but we decided not to rush it. We worked first on building a relationship with Barbara to make her more comfortable emotionally.

Over several weeks, we met regularly and spoke to her on the phone often. We guided Barbara through checking her blood sugar using her forearm, which was less painful and frightening to her. (We also trained her to use her fingertips, because patients can't use alternate sites under certain conditions.) We also encouraged her to take oral medications under close supervision.

Because Barbara's blood sugars were so high, we knew that would most likely require insulin to get and keep her blood sugars in a healthy range. But she hated needles and felt that people would stare at her if she had to take an injection when she was out in public. So we introduced her to the insulin pen; she agreed to use it. Today, she takes three shots of insulin a day, her blood sugars are in her goal range, and she feels good. She alternates follow-up diabetes visits with us and an endocrinologist (who is our collaborating physician). She sees her primary care physician for other health problems and prevention. This approach to care may well represent the best of all possible worlds.

Many of the strategies we used with Barbara employed traditional nursing techniques: communication, support, and relaxation training. At the same time, we used our medical expertise in prescribing appropriate medication, medical equipment, education, and training.

This combination of medical knowledge and nursing techniques is a tremendous asset in the care of people living with diabetes. The diabetes nurse practitioner, wearing both hats, is comfortable practicing in this blended role. 

    Jane Jeffrie Seley, GNP, MPH, MSN, CDE, is a diabetes nurse practitioner at Mount Sinai Endocrine Associates, New York, and Marie K. Medenilla, RN, BSN, is a nurse practitioner candidate at New York University. Medenilla completed a clinical rotation at Mount Sinai Endocrine Associates; Seley served as her mentor. 

This article originally appeared in Diabetes Forecast, July 2003, pp. 94-96 and is reprinted here by permission of the copyright owner, Jane Jeffrie Seley.

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