Managing Type 2 Diabetes During COVID-19: a Guide for Primary Care Providers

Last Updated: October 6, 2020

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The following condition-specific resources were developed in the context of the COVID-19 pandemic, when necessity required deviation from existing evidence-based guidelines as in-person visits were significantly limited. Certain frameworks and guidance within the resources are applicable only to the “crisis care” needs during the COVID-19 pandemic and should be reviewed with this consideration in mind. Established Clinical Practice Guidelines are the authoritative source for evidence-based care for each condition.

During the COVID-19 pandemic, we should be taking a virtual-first approach to diabetes care. The relative benefits and risks of an in-person versus virtual diabetes visit will depend on several factors, including an individual’s capacity for using technology, the extent of their disease and local COVID-19 prevalence. Regardless, most diabetes care and support can be delivered through virtual ‘visits,’ phone, video or secure messaging. This resource is meant to supplement the Diabetes Canada guidelines by indicating ways to adapt care for type 2 diabetes during COVID-19. It may also be useful for people with pre-diabetes. See guidelines.diabetes.ca for full guidelines and decision support tools for diabetes management. 

 Self-management is a core element of effective diabetes care and is essential during COVID-19. Two virtual resources to support self-management in people with diabetes and pre-diabetes include: 

  • 1-800 BANTING (226-8464): People living with diabetes can call to speak with live diabetes educators 
  • Canadian Diabetes Prevention Program: People living with pre-diabetes can self-enroll in this free, online, 1-year healthy behaviour coaching program 
Continue
  • In-person visits for patients with limited capacity to engage virtually.
  • A1C testing every 3 months for patients with A1C ≥8 (Note: A1C target for most individuals remains <7%).
  • Assess medication adherence at every visit.
  • Support self-management through education and personalized goals.
  • Annual lab work for renal parameters (creatinine and urine ACR).
Shift to
  • Conduct virtual visits when possible, based on disease severity and self management capacity.
  • Collect relevant information virtually before an in-person visit to minimize time in clinic.
  • Ask a patient to self-monitor weight and blood pressure if possible.
  • Support a patient’s self-management with high-quality apps.
  • Check cholesterol every 3 years if the patient is on a stable statin dose, their LDL is on target and medication adherence is good.
  • Cluster labwork to avoid repeated lab visits.
Delay
  • If A1C <8%, delay frequency of A1C testing to a 6-9-month interval. Use smart self-monitoring of blood glucose (SMBG) as a proxy.
  • Delay the start of ACEi/ARB to 2 weeks before the patient’s next scheduled labwork if using only for cardiovascular risk reduction.
  • Defer screening ECGs (for those with no symptoms).
  • Defer retinopathy screening to a 2-year interval (for those with no previous eye disease and A1C <8%).

Click below to view recommended schedule updates, management changes to consider, information on digital health apps and more:

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Schedule

Virtual visit (every 3-6M) 
  • A Assess glycemic control using A1C and/or smart glucose self-monitoring, and assess for hypoglycemia.
  • B BP measured at home.*
  • C Assess cholesterol medication adherence and the need for lipid testing.
  • D Assess appropriateness of drugs for CVD risk reduction.
  • E Exercise, healthy eating, and weight check.
  • S Self-screening for feet using Ipswich Touch Test.
  • S Smoking cessation.
  • S Self-management support (provide apps, connect to resources, support medication adherence, extend prescription refills until next scheduled visit).
In-person visit (at least annually**) 
  • Review glucose meter and log results.
  • Foot examination (if concerns present on self-screening or unable to self-screen).
  • BP machine calibration (if concerns with home BP).
  • S Shots/immunizations (unless can be completed at a pharmacy).
Lab testing and referrals 
  • A1C: Every 6-9M if <8%; every 3M if ≥8%.
  • Cholesterol: Annually if above target; every 3Y if on stable statin dose, LDL on target, and med adherence is good.
  • eGFR, urine ACR: Annual.
  • ECG: Defer if no symptoms.
  • Retinopathy screening: Defer to a 2-year interval if no previous eye disease and A1C <8%.

* If a patient is unable to measure BP at home, then measure BP in-person in the clinic, Q6-9 mo if BP is near target and stable. 
**Patients may require more frequent in-person visits depending on risk factor control and their capacity to engage in virtual care.

ABCDES: Management changes to consider during COVID-19

A

A1C

Resources for patients

B

BP
  • Educate and enable patients to self-monitor BP at home if possible. An office BP target of <130/80 means a home BP target of <125/75 See: Home Blood Pressure Monitoring: Treatment Targets (BHS).
  • If the patient is unable to measure BP at home, then measure BP in-person in the clinic, Q6-9M if BP is near target and stable.

Resources for patients

C

Cholesterol

D

Drugs for CVD risk reduction
  • Start statin, ASA, SLGT2i/GLP1ra as per Diabetes Canada guidance for cardiovascular risk reduction.
  • If using only for cardiovascular risk reduction, delay the start of ACEi/ARB to 2 weeks before the patient’s next scheduled labwork (to assess for Cr & K+).

E

Exercise and healthy eating
  • Recommend resources for aerobic and resistance activity, while maintaining COVID-19 safety precautions.
  • Self-monitor weight at home.
  • Consider virtual diabetes education referral.

Resources for patients

S

Screening

Feet

  • For patients with a caregiver, consider home foot screening using the Ipswich Touch Test (Diabetes UK, 2012).
  • Use a photo or video for virtual visual assessment of the feet. If the patient is unable to do foot screening at home, assess annually or sooner if there are concerns.
  • Educate the patient on ‘danger signs’ that require an in-person assessment.

Resources for patients

Cardiac

  • Defer cardiac screening for those with no symptoms.

Kidney

  • Continue to test for eGFR and ACR yearly, or more frequently if abnormal.

Retinopathy

  • Retinopathy screening interval can be increased to every 2 years for those with no pre-existing eye disease and A1C <8% (CEBM, 2020).

S

Smoking cessation
  • Support patients to quit smoking while considering challenges related to mental health distress during COVID-19.

Resources for patients

S

Self-management
  • Consider virtual diabetes education referral.
  • Recommend evidence-based programs, apps, or other supports for self-management.
  • Screen for and support individuals with increased socio-economic challenges. See: COVID-19: Social Care Guidance resource (CEP).
  • Screen for and support individuals with worsening mental health and addictions.
  • Assess for and support medication adherence. Ask: “How many doses have you missed in the last week?”. Extend medication prescription refills until the next scheduled diabetes review.

Resources for patients

S

Shots (Immunizations)

Resources for patients

S

Safety

Resources for patients

Digital health apps

Digital health apps can support self-management in some patients through data tracking and education. The decision to use an app should be based on the personal goals and preferences of each patient. When recommending apps for diabetes self-management, it’s important to consider the following:

  • Most apps focus on blood sugar management and not other parameters such as BP, cholesterol, weight, or smoking.
  • Many free apps include advertisements and require paid app upgrades for features such as data sharing with a primary care provider.
  • Most apps have complex privacy disclaimers that imply the vendor can share patient data with others.

Many glucometers have a specific app that can help patients store and share data. Popular apps not linked to a specific glucometer include:

  • Health2Sync
  • MySugr

For Ontario providers

Jump to:

Local services for patients living with type 2 diabetes

This resource is designed to support primary care providers in Ontario identify local services and supports for their adult patients living with type 2 diabetes, including education programs, eye care, diet and nutrition and foot care services. Select your region:

Diabetes billing codes during COVID-19: temporary payments equivalent to selected management fees

Ministry of Health (MOH) is allowing K081 code to qualify providers to bill the Q040 code in 2021 (provided that you have use the Diabetic Diagnostic Code -250 with them, and document care with a diabetic flow sheet*), for those patients with diabetes who you are actively managing.

Scroll (left-right) for details
  • Q040

    Service provider: Family physician

    Fee: $60.00

    Service description: GP/FP-Diabetes management incentive-annual.

  • Temporary code
    K081

    Service provider: Family physician

    Fee: $36.85

    Service description: Intermediate assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes. Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes.

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    Notes

    • The services must be documented on the patient’s medical record or the service is not eligible for payment.
    • Can include the provision of a new prescription or prescription renewal, if rendered.
    • Not eligible for payment for anticoagulant supervision by telephone (G271) or any other telephone advice services listed in the Schedule of Benefits for Physician Services.
    • Eligible for any applicable after-hours premiums.
  • K030

    Service provider: Family physician

    Fee: $40.55

    Service description: Diabetic management assessment.

What does this mean to you?

  • If you have seen a diabetic patient and completed a diabetic flow sheet* a minimum of three times between April 1, 2020 – March 31, 2021 you can submit a Q040 code following the third visit.
  • If you saw your diabetic patient in-person then you would have billed the K030 but after March 17, 2020 you may have only seen them virtually and as a result, you would have had to bill the K081 code.
  • So your billing history for that patient during that 12-month period could look like any of the following combinations, which would all qualify you to bill the Q040:
    • K030, K081, K081 OR
    • K081, K081, K081 OR
    • K030, K030, K081
  • There are no specific limits to the number of K081 codes you can bill per patient, however when combining these codes with the diabetes diagnostic code (250), follow the maximums set for the regular diabetes billing codes (K030 and Q040). K030 is limited to a maximum of 4 per patient per 12-month period, and Q040 is limited to a maximum of 1 per patient per 12-month period.

Other notes:

  • The K081 is included in-basket for capitated and salaried primary care enrollment models, and Q040 is out of basket.
  • When you are billing for visits done with diabetic patients via OTN then use code K030.
  • The new K codes can be used for follow-ups. Use the code with the closest workflow and dollar value.

For more information see Equivalent Payments for Selected Premiums and Management Fees related to the Temporary COVID-19 Virtual Care K-Codes (MOH, 2020).

* A completed flow sheet or other documentation tool that demonstrates that all of the required elements of comprehensive diabetes care, as per the most current Diabetes Canada guidelines, has been provided to the patient for the previous 12 month period.