You probably know by now that our correspondent Wil Dubois attended the big annual American Association of Diabetes Educators (AADE) meeting last week in Orlando, FL -- from his initial reports on diabetes device integration news and yesterday's Exhibit Hall coverage.
Today Wil turns his attention to the business of Diabetes Education itself at AADE, reporting on some key sessions and the overall atmosphere of this year's conference.
The official theme was "refresh, recharge, renew," but on the ground at the 41st annual AADE meeting, the reality was that there seemed to be a lot of fear about the future of diabetes education in the faces and voices of attendees. And the gathering continues to shrink -- morphing in the exact opposite direction of the growth in diabetes itself, and in opposition to the new national emphasis on earlier health interventions.
Fewer and Fewer...
Organizers estimated that about 2,500 CDEs (certified diabetes educators) came in for the conference, which AADE's public relations staff said was about 150 fewer attendees than last year. The PR folks were quick to play down this stat, pointing out that attendance always varies year to year. But overall there's no doubt the organization has seen a slow and steady decline in attendance during the past few years, a fact that most definitely loomed over this year's meeting.
Why the Shrinkage?
- The No. 1, rather startling reason, was simply that fewer diabetes educators have jobs. Nearly every member I talked to had at least one colleague who had been let go, especially from the hospital environments. Several reported that they were the last remaining member of programs that in the past had employed as many as half a dozen educators. (See also: Amy's 2007 report on "The Crisis in Diabetes Education")
- Related to the reduction in workforce is a reduction in employer support. I was shocked to learn that the vast majority of educators were forced to take vacation time and traveled on their own dime to attend this professional gathering.
- One CDE also told me that many of her peers simply couldn't justify traveling a great distance when continuing education credits (historically one major reason for attending the meeting) can now be obtained more affordably from online classes.
We also couldn't help wondering if the new ultra-conservative splinter group that broke off from the AADE earlier this year (the Academy of Certified Diabetes Educators, or ACDE) might not have siphoned off some membership as well, either directly or indirectly. If enough folks are disenchanted with the current direction of the AADE, perhaps some have just "thrown in the towel" on attending this meeting.
Even so, the AADE was able to pull representation from each of the 50 States, as well as 20 foreign countries. So clearly many members still see value in the annual conference. From what I saw, the educational sessions were generally well attended -- including two dealing with the Diabetes Online Community (DOC) and power of social media! -- and some were even packed to the gills, with educators sitting on the floor for lack of chairs. By my count, there were 97 different educational sessions to choose from over the four-day run of the conference.
Changes in American healthcare, especially the Affordable Care Act and the issue of reimbursement, were important themes that wove their way throughout many of the sessions this year (don't worry, I've got a full report coming on that in a separate post next week).
An observation: many educators had angry things to say about their employers, health insurance, healthcare reform, doctors, and even structural nuances in how educators operate -- but very little of that frustration and animosity was aimed at us patients. I've sometimes attended medical conferences and left wondering why those people were working in diabetes care at all, but not so with AADE. While I never heard the phrase "person with diabetes" even once, at AADE the term "diabetic" had a soft tone, and when the educators talked about their "patients" it was with possessive warmth.
Overall, I got the feeling that the vast bulk of educators present genuinely cared for their patients and wanted to help. They seemed often befuddled by our (irrational) behavior, but seemed accepting of us in all our human frailties, and were comparing notes with each other on what works and what doesn't when it comes to motivating patients with much discussion of shared decision making, active listening, and communication.
Then, there were the "official" tones of the conference...
Proving Their Worth
During the opening session, current AADE President Joan Bardsley set the tone that would resonate through out the rest of the conference: Diabetes Educators are being left behind in the evolving world of healthcare, and the only way to turn the tide is to prove their worth. In her words, "Illustrating the value of diabetes education is Job One."
It may interest you to know that there's actually a lack of strong data supporting the notion that diabetes education helps people with diabetes achieve better outcomes. Huh? How can that be? Well, partly because the subject is only lightly studied, and partly because frequently diabetes education really doesn't help — at least not as it's generally offered today with limits placed on the number of hours per year, and the common requirement that much of the education be in a group format.
To build a better evidence base for the effectiveness of diabetes education, Bardsley urged her members to "think on the macro level" and to "track outcomes."
"We need to prove our value," she told them, "we need to make our case and communicate our worth."
The problem for the AADE, and for the profession, is that our country is in the midst of a transition from a pay-for-service to pay-for-performance model of healthcare. So unless diabetes educators can somehow prove performance, there will be no pay. Complicating things is the fact that a large part of diabetes therapy is pharmacology and, in general, diabetes educators are not authorized to prescribe medication.
Bardsley also said the organization would continue to push for state licensure of educators as a key goal to expanding scope of practice, thus increasing the likelihood of reimbursement from health insurance payors. She also, surprisingly, urged members to basically go door-to-door and beg local doctors for referrals. To help with that, Bardsley said the AADE is planning a promotional campaign aimed at the general public. No details were given, but in my head I could hear a voice saying, "Ask your doctor if Diabetes Education is right for you."
Battle Over the Un-Certified
There was a whole new category of diabetes educator unveiled at this meeting -- one for un-certified medical workers and paraprofessionals, to be called the Associate Diabetes Educator (ADE).
My mind was blown. Did the AADE finally wake up and realize there are not enough CDEs on the planet to meet the current and rising need? Did they realize that there's an untapped wealth of knowledge and experience out there among patients and community educators like me just waiting for a way to lend a helping hand?
I should have known better.
It's a little unclear exactly how this is going to play out, but the AADE has scrapped their old obtuse system of six levels of practice, and replaced it with a new one that has three levels, presented by past AADE President Sandi Burke in a session called "Levels of Practice for Diabetes Educators" (see this PDF on their new "career ladder"). Yes, there is a proposed "Level 1" ADE designation that "includes, but is not limited to lay health, community health workers, peer counselors, health navigators, health promoters, health coaches, and assistive school personnel with some level of preparation in a recognized healthcare field."
But it's not clear how welcomed they would be in the AADE organization itself. What they're essentially proposing here is to remove all community health workers, medical assistants, paraprofessionals, and lay healthcare workers from the AADE official levels of practice and rather park them in a separate ADE corral. I kinda liked the ring of that title originally, but the rank-and-file educators in the room did not. They drew their swords and started cutting away at it as soon as the microphones were turned on for the Q&A session that followed the announcement of the new scheme.
As mentioned during that session, there is no test, validation, or certification for these ADEs. Some wonder if it's just an empty title, or maybe it's a way the AADE has found to appease those who joined the earlier-mentioned Academy who are convinced that full certification is the only acceptable path.
Burke was clear on the point of this new role: "Providing information is different from education."
Huh? I guess in her mind, un-certified personnel are incapable of educating others, and should stick to cutting the tape that seals the glucometer boxes, and maybe downloading patient meters for the CDEs (after polishing their shoes, of course). I can't tell you how many "certified" educators I've met who can't educate themselves out of a circus tent with a flashlight and a compass; while on the other hand, over the years that I taught for the University of New Mexico's Project ECHO, I worked with well over a hundred native community health workers who blew my mind with their ability to teach -- to educate -- and to motivate their people despite the lack of certification (or even a high school education, for that matter).
For me, the final nail in the coffin was Burke's response to one of the attendees who voiced concern that the ADE title sounded too much like a real diabetes educator: "An ADE is not a Diabetes Educator any more than a nurse's aid is a nurse."
I also got my first taste of a clearly growing divide between CDEs who work for healthcare organizations and the growing number who instead work for industry. One especially heated exchange came ironically during a session titled "Adventures in Alice's Wonderland: Diabetes Educators and U.S. Health Care," with CDEs from both camps trashing the "other side" and defending "their side." It was quite the spectacle. I couldn't help but remember Rodney King saying, "Can't we all just get along?"
IMHO, it's kind of pathetic. We've got an epidemic here, People. In my book that's the only fight that matters. We need all hands on deck. Can't we all just get along?
The Times Are a Changin'
Speaking of epidemics, even Bardsley pointed out the recent, in her words, "bad day," when the CDC announced a three-million-person increase in the number of people with diabetes in the United States. That begs the question: With an epidemic swallowing us all up, and seeing how much the AADE is struggling to stay relevant to its own members, what will the new leadership do about it? Somehow I think they need to do more than just buy ads asking if diabetes education is right for you.
Of course, you can't ignore all the good that is coming from the educator ranks -- and from this conference, in terms of embracing the patient community in new and positive ways. Just look at the two social media sessions that were well-attended, and led by a group of vocal patient D-Advocates including Cherise Shockley, Bennet Dunlap, Kerri Sparling, and Jeff Hitchcock. The latter three were on a panel with Dr. Jill Weissberg-Benchell and Jen Block, a Stanford educator with type 1 diabetes, while Cherise led a panel with incoming AADE President Deb Greenwood.
Other D-Advocates attended too, and we all weaved our way into different parts of the meeting; it 's very encouraging indeed to see how the educators are embracing us. Some of the DOC session tweets can be found at Twitter hashtags #AADE14SocialMedia and #AADE14 and via great tweeting coverage from the diaTribe team.
That is a change that's been in the works, and continues to grow as we get ready to welcome in the AADE's new leadership with Deb Greenwood and Hope Warshaw -- two educators who fully back the DOC and patient peer support.
Thanks for the insightful report, Wil. We're on the edge of our seats to find out how things develop in this controversial world of Diabetes Education.