For years now, we've complaining about the state of diabetes education in this country: overworked educators, near-impossible hoops that prospective CDEs have to jump through, and difficulties in getting reimbursed by insurance companies (so what else is new?). Who read my big exposÃ© article on this issue waaay back in 2007?
We DOC advocates met with representatives from the American Association of Diabetes Educators (AADE) at the second Roche Diabetes Social Media Summit in 2010, but that meeting of the minds didn't exactly go as planned. Diana Pihos, the organization's Director of Communications, wasn't prepared for our onslaught of criticism. Afterwards, however, she shared her positive feedback about what the AADE planned to do to improve the quality and availability of diabetes education.
It's now been FOUR YEARS since the initial article, and a year since Diana's post, so we were wondering... Are things getting any better? What has the AADE done to address the most salient problems?
A Guest Post by Donna Tomky
It's no secret that the American healthcare system is not adequately meeting the needs of patients—and those with diabetes in particular. While there is movement toward patient-centered, preventative, and chronic care models and services, too many healthcare providers and payers continue to adhere to an outdated, ineffective, and expensive way of doing business. This situation is particularly concerning when viewed in the context of the diabetes epidemic. In the coming years, the number of individuals with diabetes will increase exponentially...taxing an already over-burdened healthcare system.
Amy Tenderich's article in the 2007 issue of Diabetes Health Professional, "The Crisis in Diabetes Education: Essential Care That's Riddled with Problems and What We Can Do to Fix It," identified several of the key factors that have prevented diabetes education from growing as a profession and becoming a more widely-used benefit, including the lack of a viable career path for diabetes educators, limited patient access, and variations in the quality and nature of diabetes education services support and reimbursement.
I'd like to thank Amy for asking us to provide an update on the developments that have been made since her article was published. AADE recognized the same challenges she mentions in her article and we have been systematically addressing them for the past several years. I'm pleased to report that much has been accomplished and a solid foundation has been laid for the future growth of the diabetes education.
DSMT = Diabetes Self-Management Training (official term for working with a CDE)
Defining the Diabetes Educator Career Path and Diminishing Barriers
One of the most significant ways that the discipline has been strengthened since 2007 is by the development of documents that support and clarify the roles and scope of practice for diabetes educators. In 2009, AADE released The Guidelines for the Practice of Diabetes Education and the Competencies for Diabetes Educators. This groundbreaking document outlines the various levels of practitioners (see below), their level of responsibility and the specific knowledge, content and abilities that are needed to practice at that level.
The Guidelines are inclusive and specifically include a place for community health workers and other non-healthcare professionals who can reinforce the messages of diabetes education in the community and provide vital support to individuals with diabetes:
- Level 1 - the non-health care professional that is typically a community health worker or healthcare technician
- Level 2 - the health care professional that occasionally educates a person with diabetes as they provide medical support
- Level 3 - the health care professional that may specialize in diabetes education but who is not yet a certified diabetes educator
- Level 4 - the Certified Diabetes Educator (CDE)
- Level 5 - the diabetes educator that has advanced skills and experience to develop and manage diabetes education programs or provide comprehensive clinical management. The CDE credential or Board Certification in Advanced Diabetes Management (BC-ADM) is a necessary prerequisite for this level.
The Guidelines were accepted by the National Guidelines Clearinghouse in June of 2009 and were incorporated into the clearinghouse later that summer (NCG is made available by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services). This means that the guidelines are widely available for review by health care professionals and the public, although the details of how individuals will be officially certified and recognized at these various levels are still being worked out.
To this end, the guidelines are being used by several programs seeking accreditation through AADE's Diabetes Education Accreditation Program and are being examined in an AADE pilot study that integrates multi-level DSMT teams into patient-centered medical homes. AADE also uses the guidelines and levels to help us classify our professional development opportunities with an eye towards meeting the needs of all levels.
Another barrier that Amy identified in growing the diabetes educator workforce is the process for earning a credential.
The National Certification Board for Diabetes Educators has lowered the required number of hours to 1,000 in order to sit for the exam. This development should remove some of the barriers to becoming a diabetes educator.
Establishing State Licensure for Diabetes Educators
Another way to potentially alleviate this catch-22 is by establishing State Licensure for Diabetes Educators.
At this time, there is no way of recognizing qualified professionals who are practicing diabetes educators with or without a voluntary CDE or BC-ADM credential. Licensure for Diabetes Educators would set the minimum quality standards and the scope of practice for the diabetes educator. It will ensure that all healthcare providers who deliver diabetes education will have sufficient knowledge to provide safe, effective care to persons with diabetes. And by doing so, will provide a clear entry point for diabetes educators who can then pursue credentials, if they wish.
Establishing state licensure for diabetes educators is a long-term endeavor. For it to have a significant impact at the national level, quite a few states will need to establish licensure. AADE only recently embarked on this initiative on a state-by-state basis, and Kentucky was the first. Several other states have stepped forward to be next. Each state sets their own requirements for licensure, so the Kentucky regulatory bodies are now determining the specific qualifications for KY licensure for diabetes educators.
AADE does have recommended requirements for state licensure, and while we provide these to the state leaders, the actual specifics of the legislation are up to the state's regulatory body. While advocating is really up to the educators and individuals within those states, AADE provides support and resources to help them get organized and start the legislative process.
New Delivery Models Expand Access to Services
Improving access to diabetes education has been a major strategic priority for AADE for several years. To that end, we have been proactive in exploring the potential of new delivery models as they emerge.
We are particularly pleased to begin work on a new demonstration project focusing on mobile health. With the Office of Minority Health, Baylor Diabetes Health and Wellness Institute and AT&T, we are facilitating a project that will connect diabetes educators with patients via mobile technology and video platforms. We believe these mobile technologies have huge potential to revolutionize the way educators can interact with their patients and increase access to diabetes education services, particularly in rural and underserved areas.
Improving Reimbursement for Diabetes Education Services
If we hope to grow the profession and increase both the number of diabetes educators at all levels and the number of individuals taking advantage of our services, we must focus on the "bottom line." Diabetes education must become profitable, and to do this, reimbursement levels must be increased. Although our work is not done, AADE has made some positive progress in this area over the last year.
Together with other diabetes organizations, AADE petitioned CMS (Centers for Medicare & Medicaid Services - the organization that determines coverage) to increase reimbursement for DSMT services. Our efforts succeeded and a significant increase was effective January 1 of this year (for example, coverage for 30 minutes of one-on-one training went up to $54.70 from $23.45). Also, DSMT has been added to the list of reimbursable telehealth services, meaning that programs are getting paid more for these services -- which has the potential to increase clinics' profits, helping them to remain financially viable now and in the future.
Another way that we are approaching this issue is by continuing our efforts to get CMS to recognize credentialed diabetes educators as providers of DSMT at the national level via House Bill 2787 and Senate Bill 1468.
Much Progress Has Been Made, But Work Continues
AADE recently commissioned a study to help us understand the current landscape of diabetes education and to determine the future demand for and supply of diabetes educators. The study showed that as the diabetes epidemic worsens, the demand for diabetes educators is projected to increase by at least 60 percent between now and 2025. This number will increase exponentially if more individuals — such as those with pre-diabetes — become eligible for diabetes education.
The progress we've made over the last few years has significantly strengthened the profession and has positioned us for growth. But work still needs to be done. We will continue to work toward refining the profession, increasing access to and awareness of diabetes education, exploring new technologies and delivery models, and improving reimbursement for services.
We at the 'Mine are 110% behind increasing quality of and access to diabetes education — so we're crossing our fingers (and toes) that the work of the AADE here makes an impact. Any prospective CDEs in the audience?