It’s pretty obvious to most people that some things just go better together, like, say, ketchup and French fries. Or beer and baseball. Ginger Rogers and Fred Astaire.
But it took the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA) -- arguably another logical pair -- more than three decades to wake up to the fact that diabetes education and ongoing diabetes support go together like Batman and Robin.
In the most recent update of the joint organizations’ 34-year-old National Standards for diabetes education (last updated in 2014), the two organizations linked diabetes management education and ongoing diabetes support for the first time. According to a joint press release from both orgs, the combination of support and education was recognized “to reflect the value of ongoing counsel for improved diabetes self-care.”
About. Flippin’. Time.
We in the DOC have known this and been screaming about it for years. This is not an educate ’em and leave ’em kinda disease. Knowing what to do and keeping current with the changes is only half the battle. Having the ongoing support to engage in the never-ending struggle is a critical component of success.
This new emphasis on support in the these standards is long overdue, and it sounds wonderful on the surface.
But how does it play out in the 11-page document? A document that was created by 22 diabetes educators, who apparently reviewed 180 research studies?
The new Standards were published online July 28, and will appear in print this fall in the two organizations’ flagship publications: ADA’s Diabetes Care and AADE’s The Diabetes Educator. The new guidance document lays out broad recommendations for diabetes education and support, and the programs that offer them, in the form of 10 new Standards.
First off, a vocabulary lesson. To reflect the change in emphasis, we've switched up terminology:
- No more DSME, which for decades has stood for Diabetes Self-Management Education.
- The new standards introduce DSMES, or Diabetes Self-Management Education and Support. (I can’t decide if that sounds more like a messy disease or a misspelling of the capital of Iowa in a careless text message.)
It doesn’t exactly roll off the tongue, does it?
Anyhow, many of these new standards deal with program structure.
Standard 1 deals with program internal structure, while Standard 4 urges the establishment of a “Quality Coordinator” to oversee DSMES services and Standard 10 is dedicated to Quality Improvement measures. Meanwhile, Standard 9 deals with tracking outcomes, and Standard 3 discusses how to evaluate the population served.
Then, there's the whole aspect of who takes a part in diabetes care program design - which is where Standard 2 comes into play, advising “stakeholder” input. You might think that the stakeholders be would largely PWDs, but you’d be mistaken, although we are part of the recipe. Stakeholders also include “referring practitioners and community based groups that support DSMES.” Some of these folk likely live with diabetes themselves, but PWDs are not a specific designated stakeholder.
Health clubs are given as an example. Go figure.
Standard 5 establishes who should be on a DSMES team. At least one member is supposed to be a CDE or a doc board certified in advanced diabetes management (BC-ADM), although I was happy to see that the new standards are making room for “diabetes paraprofessionals” under supervision. In fact, peer educators are specifically mentioned in the new standards with the charter that we could, “instruct, reinforce self-management skills, support behavior change, facilitate group discussion, and provide psychosocial support and ongoing self-management support.”
It’s good to see that the accumulated experiences of PWDs are being recognized as the gold mine they truly are.
Standard 6 addresses Curriculum, and still pushes the AADE’s stale Seven Self-Care Behaviors, but cracks open the door to new tech approaches to delivery.That's consistent with the big "digital health" theme at the AADE's recent annual meeting in early August.
There is some promise in Standard 7, which deals with ‘Individualization’ and calls for the healthcare team and the patient to jointly identify needs, and co-develop individualized DSMES plans. Again, a great concept, but how will it be realized?
Defining Patient “Support”
OK, so where exactly is all this new support that’s the second “S” in DSMES?
That’s addressed in Standard 8, Ongoing Support. The introduction to this section flatly states that education is “necessary” but that “it is not sufficient for participants to sustain a lifetime of diabetes self-management.” It goes on to quote research showing that the effects of diabetes education—as impactful as medications in helping make metabolic improvements when first given—only last for about six months. For education to have a sustaining effect, ongoing support is needed.
The new National Standards go on to give a long list of effective support systems including support from diabetes educators, trained paraprofessionals, peers, and community-based programs.
One bright spot is that the document gives the stamp of approval for tech-based support by “text, e-mail, social media, web-based, mobile, digital, and wearable and wireless devices,” and notes that peer support using social networking sites has been shown to be especially effective in helping type 2s with glucose management.
Evaluating the Evidence
Like all official medical standards of care that need to be evidence-based, these new ones come complete with four-and-a half pages of references (roughly 40% of the document).
However, unlike the ADA diabetes treatment standards, these new DSMES recommendations don’t weight the various sources of evidence. That is, every diabetes treatment guideline from ADA is assigned a grade, categorizing the strength of the evidence supporting the recommendation. For instance, diabetes education itself has a grade of B in the 2017 ADA standards of care, meaning that there is “supportive evidence from well-conducted cohort studies” rather than the higher grade of A given to recommendations that are supported by “clear evidence” of value.
While one could argue about the integrity of the grading system itself, it seems important to look closely at the credibility of the various studies cited.
I also found the new DSMES guidelines to be somewhat skeletal compared to most sets of medical standards I’ve read. The tone of the document seemed like someone lecturing about what you should do, but providing no details about how to go about it. It reminded me of an overweight know-it-all uncle giving his nephew advice on how to exercise and eat right.
No Support for ‘Support’?
In the introduction to the new standards, a cautionary note is made: “The Standards define timely, evidence-based, quality DSMES services that meet or exceed the Medicare diabetes self-management training (DSMT) regulations, however, these Standards do not guarantee reimbursement.”
Put more bluntly to diabetes professionals: Even though we think we can prove this works, you might not get paid for it.
That being the case, should we expect any major changes rolling out in the real world of diabetes care?
Getting payors to better cover education and support seems unlikely to me in the current economic, political, and social environment. Even if research shows better long-term clinical outcomes, it’s a hard sell in a shortsighted profit-driven healthcare system in a state of chaos.
So how do these two organizations hope to change that?
“The current Standards’ evidence clearly identifies the need to provide person-centered services that embrace the ever-increasing technological engagement platforms and systems. The hope is that payors will view these Standards as a tool for reviewing DSMES reimbursement requirements and consider change to align with the way their beneficiaries’ engagement preferences have evolved.”
“The hope is…”
Well, we can all hope -- mostly that ADA and AADE will be successful lobbying for change in our health insurance reimbursement system.