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We delve into the challenges faced by individuals who navigate complex health care systems with multiple chronic conditions. Our guest, Gary Marc Rothenberg, a podiatrist, shares his expertise and perspective on Maria’s journey, highlighting critical moments, socioeconomic factors, and gaps in care coordination. Together, we explore actionable strategies to improve chronic disease management and enhance access to quality care for vulnerable populations.

Gary Marc Rothenberg is a podiatrist.

He discusses the KevinMD article, “There’s no place like home when it comes to health care, except for those who fall through the cracks.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Gary Rothenberg. He’s a podiatrist, and today’s KevinMD article is “There’s no place like home when it comes to health care, except for those who fall through the cracks.” Gary, welcome to the show.

Gary Rothenberg: Thanks so much for having me today. Appreciate it.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Gary Rothenberg: Yeah. So, again, Gary Rothenberg, practicing podiatrist, been in practice about 25 years now. I’m an associate professor at the University of Michigan in the department of internal medicine and the podiatry section. Help run our fellowship in limb preservation, hopefully we’re addressing issues in prevention of lower extremity complications among people living with diabetes.

I’m also the director of medical affairs for Podimetrics. We are a mission driven company, again, to hopefully avoid preventable amputations among people living with diabetes, through technology really connecting data, patients, and providers.

But finally, probably the most important title I have is Dad, and I have a son with type 1 diabetes. So all of that together, learned a lot living as a family with diabetes, probably more than I ever learned in school. But all of that kind of combines to personal and professional passion for avoiding complications in people living with diabetes.

Kevin Pho: All right. So you’re in that tech space where you’re using technology to help with that intersection between all the foot problems that diabetes brings. So in general, what kind of tech solutions are we talking about?

Gary Rothenberg: Yeah, so we love to focus on the high-risk patient population. We tend to risk stratify people with diabetes, and we know, unfortunately, once you have had a complication as related to foot care among people living with diabetes, unfortunately there’s a very high recidivism rate. So people experience diabetic foot ulcers, within a year or two 50 percent of those patients will experience another diabetic foot ulcer, and foot ulcers are the leading cause of lower extremity amputations.

So we’re really trying to risk stratify these high-risk patients and marry tech with patients and providers. So the idea is, at least what we do, is remote patient monitoring, temperature monitoring. Through my research work that I’ve done in the space, as well as with Podimetrics, temperature elevation or heat will precede complications of diabetes as related to the foot. So just like any medical issue, fever comes before major medical issues, so the same thing happens in the foot.

And so we’re monitoring remotely patient temperatures. Those are great preventive strategies, along with good foot health, encouraging patients to check their feet every day, wearing appropriate shoes and inserts. All of those things can help people avoid lower extremity complications.

Kevin Pho: All right. So let’s talk about your KevinMD article. It’s titled “There’s no place like home when it comes to health care, except for those who fall through the cracks.” For those who didn’t get a chance to read your article, just briefly tell us what it’s about.

Gary Rothenberg: Yeah. So last fall, I think as providers we all remember those great cases where we help save somebody’s foot, or we put them on a path towards better health. Also indelible in our minds are those episodes where the system fails our patients.

And that happened for me last fall, with one of my patients who I’d been following for many years. We called her Maria. I’ve seen her in a high-risk diabetic foot clinic for years. Unfortunately she’s already had a toe amputation, she lives with many comorbidities, as a lot of our patients with diabetes do, including some mental health issues, and some issues around SDOH, some limited financial resources. She lives far away from the clinic.

And she was hospitalized for an infected foot ulcer. She spent about seven days in the hospital, ends up going to a skilled nursing facility, and then for 30 days, and 30 days no more, according to her insurance.

I actually saw her in the outpatient clinic on the day she was scheduled for discharge from that skilled nursing facility, and there was no plan for home care. She had these bilateral foot wounds, again lives alone, and was basically told, your insurance is up, you have to go home. But there was no appropriate planning for that home care.

And of course we scrambled, we tried to get her home care. The article points out, which is 100 percent the truth, we tried 34 home health care agencies, none of them would accept her.

So of course, as you could probably predict, her outcome was worse. She ends up back in the emergency room with infected ulcers again, ends up with a prolonged hospital stay and worse outcomes.

So I think as providers, again, many of us are familiar with the weak link in the chain, which is transitions of care. And this was just where, as the article points out, I think the system failed her, she fell through the cracks, and unfortunately had a worse outcome because of it.

Kevin Pho: So you mentioned that you talked to 34 different home health agencies, none of them would accept her. What was the reason for that?

Gary Rothenberg: Yeah, I asked that question too, obviously. And this is a patient who has a care manager, a case manager, because she is deemed high-risk.

It was around Thanksgiving time, the agencies were short staffed. There was nobody in the home. The big one was, there was nobody in the home to teach the wound care that she needed. And that seems so paradoxical to me. That’s why I’m ordering the home care, is because she lives alone and she can’t logistically, physically, mentally do her own wound care. So it makes sense to me to recommend that a nurse come out to her home three times a week.

But that was the big one, is that a lot of insurance, as your listeners may know, the goal of home care is to teach somebody in the home to do the care that’s needed. She didn’t have anybody to do that.

So unfortunately they just continued to refuse. They went through 34 home agencies, and basically the resolve was, she should come to my clinic three times a week, and that maybe we could get some help with transportation.

Well, this is a lady with diabetic foot ulcers. Again, intuitively we all know being at home is the right place for her. The idea of transportation, driving 10, 12 miles to the clinic three times a week, she’s going to be on those feet much more than if we could deliver the care where she needed to be seen, which was in her own home.

Kevin Pho: So you alluded to her social determinants of health adversely affecting her health and her various complications of diabetes. So go into more detail, paint a picture about what it was like for her, and how her social determinants really prevented her from getting the care that she really needed, and in fact worsened her conditions. So for those who aren’t familiar with that concept of social determinants of health, just paint us a picture that really drives that point home.

Gary Rothenberg: Yeah. So I think we are learning, and if there’s something that I’ve learned over my career, it’s that social determinants of health, who you are, where you live, where you work, your access to appropriate health care, your appropriate food, and the environment in which you live, will directly affect your outcomes. And I’ve learned that over my career.

So again, she’s a lady with limited financial means. She’s on disability because of her mental health issues, so that plays a very significant role. She lives alone, she has no one. She’s got bilateral foot wounds.

Yes, today we can do things like Instacart, and groceries can be delivered to your home, and those are advantages, and I think we’ve made strides in the social determinants of health world. But we still understand that people like my patient, they don’t end up in the doctor’s visits for follow-up because they don’t have money to put in the gas tank, or they don’t have reliable transportation.

So those things, and I think as providers we’re fairly quick to call patients non-compliant. That’s a term that gets thrown around, and frankly it probably shouldn’t, in my opinion, as much. Because when you ask that question of, why didn’t you show up to clinic last week, Mrs. Jones, you hear things like, my car is in the shop, I didn’t have anybody to bring me, I didn’t have money to put in the gas tank.

So those are the other things, non-medically related. These patients are fighting medical issues, but then there’s also the social issues that will impact outcomes.

Kevin Pho: So talk about some of the paths forward here. What are some things that we could do to prevent more cases like Maria’s?

Gary Rothenberg: Yeah, appreciate that question. So again, I think I’ve become really kind of passionate about hopefully incorporating tech and remote patient monitoring in this space, especially among those high-risk patient populations.

So these are touch points. Remote patient monitoring, again, presuming that patients have the ability to have a cell phone or to communicate, these are opportunities to be connected, or in a very positive way, I use the word tether, tether our patients to the clinic, to their providers, to seek also affirmation and confirmation.

Many times, I think, at least in my world, I’m asking patients to do fairly complicated wound care regimens at home. And if they can send me a portal message, which can be tech, just patient portals, or utilize technology like I’m involved with with Podimetrics, I think that really can help triage patients.

And as I like to think of, we need to use tech to have the right patient seen at the right time by the right provider for the right reason. But they have to have access to us as providers as well.

Kevin Pho: So let’s go back to Maria’s case. What would that tech intervention specifically look like in her story, just so we can really paint that illustration in our minds?

Gary Rothenberg: Yeah. So we have a remote temperature monitoring mat where patients will step on it. It’s essentially the size of a bath mat, and we’re monitoring for temperature asymmetry, or differentials in skin temperatures. And when we do see that, we have a clinical team that will call the patient. Our lead is not, hey, Mr. Jones, your right foot is lighting up like a Christmas tree, but it’s, how are you today, what’s going on with you?

So it’s the touch points in between the clinic visits with your provider that I think is the secret sauce. Yes, we’re a temperature monitoring company, we’re a foot company, but the things that we hear, we have plenty of stories, again, when we lead with a how are you, we hear things like, I haven’t taken my blood pressure medicine in a couple days because I can’t get to the pharmacy to pick up those medicines.

So the idea is that we can help connect with resources in the community, or we’re aware of that. That’s how I link the outcomes to what we are doing on a regular basis.

And I think if she was on that program, people would be touching base with her. If we were able to get a home care nurse into the home, he or she would see that mat and say, hey, are you stepping on that thing, what’s going on, and how have you connected with your provider through the use of technology?

Kevin Pho: So in your case about Maria, who presumably has a lot of obstacles when it comes to her social determinants of health, do they have access to these technological solutions? For instance, if Maria was on Medicaid, what kind of access do they have to technological solutions like the one that you describe?

Gary Rothenberg: Yeah, that’s an area that we’re obviously working on. And I think, as we think about how does tech and AI and machine learning, I think I’m excited about that. And where I’m optimistic and hopeful is, some of these health plans, as you’re mentioning, especially those that assume risk for their patients, they can use AI to identify these types of patients who may benefit from it.

We do need to conduct more research, especially in that patient population, to make sure that they are included in the algorithms. But I’m excited about that potential opportunity.

But it definitely is a struggle that we’re continuing to work on, is access. The VA actually just published a paper on this issue, and making sure that even in our program, which is utilized in the VA system, we want to make sure that the patients in rural areas, for example, telemedicine and technology can really help bridge that gap because they are far away. And we want to make sure that underrepresented minorities have access to the technology. So I think it’s on people’s minds, which I think is great. But of course we do need to make sure that everybody has equitable access to tech.

Kevin Pho: So just for some context, as of today, do insurers cover technological solutions like the one that you describe? Private insurers versus government insurers, what’s the context today?

Gary Rothenberg: Yeah. So I think obviously in the remote patient monitoring world, probably the best well-known tech is continuous glucose monitoring, especially in the diabetes space. And people have worked hard, and we have seen a lot of progress in that field, where there is more access among Medicare, Medicaid patients.

For remote temperature monitoring, we’re still making strides. We do not have codes specific for remote temperature monitoring, so there is still a challenge. But at Podimetrics we’re working with at-risk populations and plans to help identify those patients who would benefit from the technology.

Kevin Pho: So specifically with your technology at Podimetrics, so you’re obviously at an academic medical center, so tell us the type of patients that you’re applying this technology to today.

Gary Rothenberg: Yeah, great question. I think it goes back to what I mentioned at the beginning, which is risk stratifying those patients.

So specifically, and what’s recommended in best clinical practice guidelines in management of patients with diabetes, is those patients that have demonstrated risk already. So to meet the criteria for a smart mat, you would have already experienced a diabetic foot ulcer, a partial foot amputation, be a high-risk patient with significant peripheral arterial disease, a Charcot foot, which is a unique form of arthritis that we see where the foot just essentially collapses, or end-stage renal disease.

Any of those patients who are deemed very high risk for recidivism, because they’ve already demonstrated, and history will repeat itself, those are the best candidates and the ideal candidates for the smart mat program.

Kevin Pho: All right. So let’s talk about a question outside of tech. So I’m a primary care physician, internal medicine, and you’re obviously a podiatrist. So in the exam room we’re always taught to look at diabetics’ feet every visit. So tell us specifically, go into more detail, what are some specific things that we should be looking for regarding patients’ feet, and what kind of specific questions should we be asking them to potentially uncover a hidden issue?

Gary Rothenberg: I love your question, and so appreciate it. We know as podiatrists our primary care physician colleagues are extremely busy. Again, especially, you see a patient with diabetes, as I say, nobody comes into my clinic with diabetes alone. They also have hypertension, hyperlipidemia, you’re dealing with shoulder pain on that particular day.

So we really recommend, one of course is, I actually have the patients advocate for themselves, and recommend, as they’re waiting on you and your colleagues, take your shoes and socks off, so that our primary care colleagues will for sure at least do a screening.

I think our expectation in podiatry is that you will do a cursory screening. And David Armstrong is a podiatrist who’s written a really wonderful article for primary care physicians called the three minute diabetic foot exam. It’s assessing for neuropathy very quickly, by asking, do you have burning, tingling, pins and needles, or numbness in the feet? Assessing for vascular disease by palpating pedal pulses. And then really again looking at the feet to see, are there any calluses, especially those that might have some bleeding underneath, significant foot deformity?

We also know that the American Diabetes Association recommends a comprehensive annual foot exam. Primary care physicians can do that, but again, we know you’re busy, we love to do that. So any patient with diabetes should be seen annually for a comprehensive foot exam.

So referral from primary care, especially if you notice something in that screening visit that tips you off that, oh, this patient may be higher risk, we’d love to see all of those patients in the podiatric clinic for a comprehensive foot exam.

Kevin Pho: We’re talking to Gary Rothenberg. He’s a podiatrist, and today’s KevinMD article is “There’s no place like home when it comes to health care, except for those who fall through the cracks.” Gary, we’ll end with some of your take-home messages to the KevinMD audience.

Gary Rothenberg: Yeah, I appreciate the opportunity to spend a little bit of time with you today. I think fee for service is still running rampant in our medical arena today, but addressing holistically the patients and focusing on prevention, I would love to get that message across. Because we know it’s the right thing, it’s ideal for our patients, it’s better for the health systems, because we know there’s cost savings associated with prevention.

And ultimately what we want is to keep these people with chronic disease, it’s hard to manage those disease processes, so we want to keep them as healthy as they can be. And I mentioned at the beginning, I have a son with type 1 diabetes, so that’s what I want for my son, is to hopefully live with diabetes for a very long time, since we don’t have a cure for it.

So focus on the holistic approach, really try and emphasize prevention, because that’s a health care system, not a sick care system.

Kevin Pho: Gary, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Gary Rothenberg: Appreciate it. Thank you so much.