History
Maria Jimenez is a 64-year-old female who comes to the family medicine clinic for a “new patient” visit. She is accompanied by a friend who translates for her. She has a history of type 2 diabetes and was recently started on insulin (by Health Center 2) due to persistently high blood sugars (300-400) despite metformin and glipizide. Her only complaints today include tingling in her feet and pain to the second toe of her foot.
Exam & Disposition
On exam, her vital signs are: BP 130/72 HR 70 RR 12 T 37.5C (99.5F) 98% RA. She has a normal physical exam except for an ulcerative lesion to the dorsum of the second toe of her left foot (see picture).
Her clinic provider, Dr. Evans, determines that she will need a course of antibiotics (cephalexin) and a referral to podiatry; she will see her in two weeks for a follow-up. She also provides Ms. Jimenez with a refill of her insulin. Dr. Evans checks Ms. Jimenez’s blood sugar (320) and advises her to take her insulin as prescribed. Ms. Jimenez’s friend explains the discharge plan to her.
You proceed with your CE screening after the attending physician leaves the room.
Ask Yourself
- What should you do before continuing your screening?
- What should you ask regarding her diabetes management and her skin infection?
Social Needs
You explain to Ms. Jimenez’s friend that it is hospital policy to use an official interpreter service to communicate with her. Her friend is fine with this. Using a language line, you determine that Ms. Jimenez hasn’t been monitoring her blood sugars at home – she didn’t know this was expected of her – and she doesn’t have a glucometer. You identify a Walgreens near her home and you call to find out a brand of glucometer, test strips, and lancets that are covered by her insurance. You relay this information to Dr. Evans. You also ask the clinic nurse to demonstrate the best way to check blood sugars using a glucometer.
Ms. Jimenez states that she knows very little about diabetes and is terrified that she will become blind and lose her legs. She also doesn’t understand why Dr. Evans is giving her an antibiotic. Finally, she explains that her insulin prescription (long-acting) is too expensive for her.
Ask Yourself
- What other questions might you ask about her issues with her insulin?
- How might you address her questions about her diabetes?
Plan
A reasonable plan to manage her issues:
Health Literacy
- Print out a description of diabetes under “Patient education: Type 2 diabetes (The Basics)” from UpToDate.
- Inform her provider/RN and ask them to explain diagnosis/management (using language line).
Medication Affordability
- Good Rx (have her download this on her phone).
- Call her RX plan or her pharmacy to see if there is another insulin that is formulary.
- Review eligibility for PACE/Pacenet on the “Top 5” list.
- Google manufacturer for discount programs if she does not have a prescription benefit.
- Refer to the practice Population Health Pharmacist for advice.
- Inform her provider who may opt for cheaper insulin alternative.
Is an Interpreter Necessary?
Patients With Limited English Proficiency
Federal law, in Title VI of the Civil Rights Law of 1964, requires recipients of federal financial assistance, including virtually all US hospitals and their emergency departments (EDs), to provide meaningful linguistic access (e.g., in-person interpreter services, language line, etc.) to healthcare for patients with limited English proficiency.
It is important to note that the use of untrained interpreters “doubles interpretation errors compared with discussions with trained interpreters...often yields significantly degraded information and may result in misdiagnoses and unnecessary testing and procedures.”
From: Brenner JM, Baker EF, Iserson KV, Kluesner NH, Marshall KD, Vearrier L., "Use of Interpreter Services in the Emergency Department," Annals of Emergency Medicine. 2018;72(4):432-437.