Having a diabetic shoe program can offer great therapeutic value to your patients and also grow your practice. Accordingly, this author details essential steps toward running and maintaining an effective diabetic shoe program.
Developing and maintaining a fully optimized diabetic footwear center of excellence is not easy. Few in podiatric medicine achieve this. In fact, as fewer podiatric physicians are developing and maintaining their diabetic shoe business, more and more pharmacies and durable medical equipment (DME) companies are finding footholds in our own backyards. While some of these non-physician shoe suppliers do an adequate job, I have found that many do not and as a result, physicians and patients become cynical about the benefits of diabetic footwear.
Having lectured and written on this topic for many years, I have noted a wide spectrum of thought among physicians regarding diabetic footwear. Some think that the diabetic footwear program is way too much trouble. Others find it valuable but enter into it with mediocre effort and training, resulting in bad outcomes.
Many podiatry practices function with the illusion that the doctor alone can achieve and maintain success in a healthy diabetic shoe program. This approach is self-defeating for many reasons that I will explore below. If the doctor is responsible for ordering shoes, completing the certificate of medical necessity (along with the comprehensive diabetic foot exam), mailing the information to the certifying physician and then having to deal with back orders and all of the patient communication that is necessary while patients wait on their shoes and paperwork, failure and frustration are most certain.
This scenario is common among podiatric practices and is why many podiatrists who fit shoes fit, on average, only five pairs a month. Many of these offices have in excess of 100 office visits per month from patients with diabetes on Medicare.
The self-limiting practice or misperception about maintaining a diabetic shoe program is that the “product” is not important. Many doctors do not ensure that they have shoe styles and types that are reasonable for the range of foot types and pathology.
Another common error among practices is a complete and utter lack of patient recall year after year among patients who have received diabetic footwear in the past. A surprising number of patients with diabetes in an average practice get fit for shoes one year and then somehow are forgotten about the next year.
Either the patient did not receive an appropriate follow-up appointment or did not get education about the need for follow up. In some cases, many patients will miss an appointment or have an accident and simply not get another appointment. Those are the patients who need reminders about their need for a diabetic evaluation and comprehensive diabetic foot exam.
Practices that allow patients to slip between the cracks year after year suffer for this economically while the patient suffers therapeutically.
Having protocols to identify qualified patients and ensure they are scheduled for a separate comprehensive diabetic foot assessment each year is fundamental. Such an approach will allow the physician to determine any changes in ulcerative risk status, qualification for shoes and, furthermore, allow for Physician Quality Reporting System incentive requirements. Many doctors find themselves too busy to train their staff or educate their patients. Accordingly, little gets done and few are fit for shoes. Additionally, without educated staff, adherence and documentation often suffer.
Success requires aligning identification, evaluation, fitting and documentation procurement along with the right adherence tools. Without attention to detail and proper staff training, diabetic shoe programs will flounder in mediocrity.
While this article is not for the purpose of convincing the cynic that diabetic footwear is valuable for patients (I assume that the enlightened podiatric physician understands this), this is a primer for how to be successful in starting and maintaining a successful program.
My definition of success in running a diabetic shoe program consists of the following steps.
The first step is successfully identifying all patients with diabetes who qualify. Some patients will have already been fit with shoes from other facilities and many more have not ever received shoes. One must train the staff on established protocols in order to identify when the patient last received diabetic shoes and determine insurance eligibility. Additionally, this means performing a thorough diabetic foot examination.
Second, success is growth. Success means that your program is growing every year. This takes education, excellent service from your office, a good product and recall for those patients who slip between the cracks with appointments.
Third and most importantly, success means providing a good product and service compliantly. This means proper documentation in the chart along with attention to DME supplier standards.
So with these things in mind, let me share with you six fundamental pearls for achieving success in maintaining a diabetic footwear program.
In my opinion, success depends on making the program’s success one person’s responsibility and establishing benchmarks at the beginning of the year on how many shoes you will fit. The diabetic shoe coordinator should have responsibility for identifying all qualified patients. If you do not have a diabetic shoe program in your office, you are likely fitting five or fewer pairs of diabetic shoes a month. If you have studied the certifying conditions that qualify one for diabetic footwear, I strongly contend that if you see 100 patients with diabetes in your office in a month, conservatively 75 percent of those patients will meet the Medicare qualification for therapeutic shoes.
The coordinator should ensure that every patient with diabetes is scheduled for a comprehensive diabetic foot exam. One should allot adequate time to allow for a comprehensive diabetic foot exam, sufficient patient education and time for selecting and measuring their shoes. Offices have the option of providing required forms to the patient to bring to the Medicare doctor. Alternatively, the DPM’s office may fax forms to the MD’s office for signature and dating. The doctor will complete the certificate of medical necessity and place the certificate alongside the comprehensive diabetic foot exam. Then this documentation will get into the hands of the diabetic shoe coordinator. Then one would measure the patient’s feet and show him or her (via catalogue, computer tablet or samples) the shoe type and style recommended by the doctor. Then the staff will mail out the certificate of medical necessity that day, not five days later or one week later.
Furthermore, the diabetic shoe program will have a spreadsheet that will indicate when the office sent the patient’s certificate of medical necessity, who received it and when the shoes came in.
In addition to this information, the patient’s shoe style and size would be included along with whether the patient received custom or prefabricated orthotics.
There are now programs available that take the job of documentation procurement out of the hands of the office. The process simply requires entering patient and shoe information into a secure website portal. The MD will be contacted twice per week to ensure that he or she complies with the Medicare requirements. The physician will then sign and fax the forms right back to your office.
The next key ingredients for a successful diabetic shoe program are the quality and the variety of the product.
It goes without saying that we are no longer just competing with other podiatric physicians for many of the services that we offer in our market. We are competing with pharmacies and other DME companies.
Carrying one brand of diabetic shoe is not sufficient to provide the wide variety of choice appropriate for a diverse patient population.
In my office, I carry well-known brands like New Balance and Brooks as well as other predominately diabetic shoe brands like Orthofeet and Apex. I carry several varieties of Lycra shoes that afford a seam-free, soft upper for those with deformities or those who use ankle foot orthoses. I carry many styles and types of shoes in order to have the best choice in my community. In my opinion, it is imperative to have a variety of shoe shapes to accommodate the variety of foot types that we see.
The key is that the doctor should have oversight over what kind of shoe the patient needs for his or her foot type. It should not be the case that patients choose the shoe without guidance. These principles are something that your diabetic shoe coordinator can also learn to avoid patients getting the wrong type of shoe for their feet.
I personally prefer companies like SafeStep that offer a variety of brands and other services that make my shoe program run more efficiently.
A successful diabetic shoe program requires training and protocols to make sure you get patients’ fit right the first time. Using a measuring device like a Brannock device does not always secure the exact shoe size you need for every brand of shoe. Some shoes come in small sizes and some come big. Additionally, it is often difficult to know the exact shoe size to order unless you have a run of shoe sizes in stock for patients to try on before ordering. Carrying a run of your most commonly used diabetic shoes in your practice is not only inexpensive. It is imperative. A conscientious diabetic shoe coordinator, with your help, will help you capture these runs for use in your office. This will often reduce returns and headaches for them in the long run.
Assessing your own diabetic shoe error rate (errors in measurements or ordering) may open your eyes to underlying problems that need to be fixed. There should not be an error rate over 10 to 15 percent when it comes to ordering and receiving shoes. If your office has an error rate above that of 15 to 20 percent, having someone come in and troubleshoot your operation can be of great help. Such an audit or training session will include performing a shoe fitting workshop or measuring clinic for your staff or diabetic shoe coordinator along with learning the shoe types and styles that are best for different foot types. The shoe sizing process is not easy and it takes staff that are trained and experienced at understanding foot types, shoe style sizing and fitting.
Training your diabetic shoe coordinator and other ancillary staff is fundamental for achieving success in your practice. The benefit of suppliers like SafeStep is that they will provide webinars and even onsite training to help support and grow your diabetic shoe program. You can prevent re-orders and mistakes the first time by simply having protocols to make sure you choose the right shoe with the right size.
Be prepared, however, to have patients tell you that they don’t wear this or that size after you have accurately measured them. Some even get fighting mad when you tell them they are truly a 10 and not a 7, which is what they have worn since 1967. Carrying a gamut of sizes of your key shoes can make sure you get it right the first time.
Another characteristic of a growing diabetic shoe program is a solid patient recall program among your diabetic patient population. This is another key responsibility of your diabetic shoe coordinator and a fundamental requirement for growth.
While there are many ways to go about doing this, there are important considerations. First, recall letters to your patients in your practice should not be a solicitation for footwear. Your letter should reflect that it is your practice as a diabetic center of excellence and that you perform a comprehensive diabetic foot examination annually for those patients with diabetes. As a part of your comprehensive evaluation, one should perform a thorough assessment of the condition of the patient’s diabetic footwear.
It is perfectly appropriate to educate your patients that they are eligible for one pair of shoes annually along with three pairs of diabetic orthotics, and that determination of need occurs as a part of your comprehensive diabetic foot examination. You should highlight that in addition to footwear, you assess the patient’s skin, nails, balance and circulation.
Your recall protocol obviously can vary but it should an ongoing process. It goes without saying that it is common for our diabetic patient population to miss appointments and often fall off the radar due to other medical problems or transportation problems. It would be appropriate that patients fit in the prior year be fit again by July. If not, suggest they return for a risk assessment to determine their eligibility and fitting if appropriate.
There is no reason why your diabetic shoe numbers should not increase every year with a good recall system.
The last and most vitally important component of a growing and healthy diabetic shoe program is peace of mind that your documentation is compliant with Medicare DME supplier standards. Medicare rules change and can be confusing. Use trusted sources like SafeStep to ensure the documentation you use is compliant and efficient to utilize.
Dr. Moore is board-certified by the American Board of Podiatric Medicine. He is the Fellowship Director of the Central Kentucky Diabetes Management program, is adjunct faculty at the Kent State University College of Podiatric Medicine and serves on the Board of Trustees of the American Academy of Podiatric Practice Management. Dr. Moore is a managing partner of Cumberland Foot and Ankle Centers of Kentucky.
For further reading, see “How To Establish And Maintain A Diabetic Shoe Program” in the October 2003 issue of Podiatry Today, “Understanding The Diabetic Therapeutic Shoe Program” in the October 2005 issue or “Secrets To Billing For Diabetic Shoes” in the March 2011 issue.