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Diabetes Educators in Primary Care—A Natural Fit

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Published Online: Nov 7th 2011 US Endocrinology, 2007;(2):15-6 DOI:
Authors: Donna M Rice
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Despite the fact that education is recognized as critical for preventing, treating, and delaying complications in serious illnesses, healthcare professionals who specialize in educating people with diabetes about effective disease management and prevention are losing their jobs.

Despite the fact that education is recognized as critical for preventing, treating, and delaying complications in serious illnesses, healthcare professionals who specialize in educating people with diabetes about effective disease management and prevention are losing their jobs.

As diabetes reaches epidemic proportions in the US and around the world, there is an ever-increasing need for diabetes educators and other healthcare professionals to provide education and care to people with and at risk of diabetes, yet hospital-based diabetes education programs are closing at an astonishing rate. This state of affairs raises pointed questions. Why does the healthcare system not adequately support education for chronic illnesses such as diabetes? Why are there so few educators and so little reimbursement for the services they provide? What will it take to change the system? How can diabetes educators reach more patients and more effectively provide them with the services needed for successful diabetes management?

Unfortunately, the current healthcare system is not designed to accommodate the increasing number of patients or the high level of specialized care required for people with diabetes. In order for education to assume its rightful position at the core of diabetes care, the healthcare community must continue to fight for reasonable reimbursement for diabetes education services and support legislation that will make it easier for patients to benefit from the skill, expertise, and support of diabetes educators. Furthermore, alternative models of healthcare delivery and diabetes management must be examined, and those that have a well-defined role for educators must be embraced.

The American Association of Diabetes Educators (AADE) has accepted these challenges and has taken steps to prepare educators for the changing landscape of diabetes care. This task prompted AADE’s adoption of the Chronic Care Model and an interest in defining new roles for diabetes educators. In pursuit of this goal, AADE participated in several strategic visioning sessions, discussion groups, and literature reviews, and found that there is a need and an opportunity for diabetes educators to provide their services in the primary care setting.

Currently, physicians in primary care sporadically refer patients with diabetes to diabetes educators. This is due, in part, to the lack of an adequate referral system, confusion about the definition of what constitutes education and what is merely information or basic skill training, competition in the marketplace for the physicians’ business, and a lack of awareness about the services provided by a diabetes educator and the benefits they can offer to a primary care practice as well as to the person with diabetes.
Diabetes Educators—What Do They Do?
Diabetes health outcomes depend on the patient’s understanding of his or her disease and the proper use of medication and devices. Equally important is the need for the patient to change unhealthy behaviors and make difficult lifestyle adjustments. The behavior-change process is hard work, and patients often need strategies and extra motivation to get their disease under control and prevent dangerous complications.

The primary goal of diabetes education is to provide knowledge and skill training, as well as to help individuals to identify barriers, facilitate problem-solving, and develop coping skills to achieve effective self-care management and behavior change. The Health Care Outcomes Continuum, defined by AADE, establishes that the unique outcome of diabetes education is behavior change. The steps in that continuum focus on four critical areas: immediate outcomes, intermediate outcomes, post-intermediate outcomes, and long-term outcomes. The immediate outcomes are learning, knowledge, and skill acquisition, the intermediate outcome is behavior change, and the post-intermediate outcome is improved clinical indicators. Finally, the long-term outcome is sustainability of lifestyle change and long-term improved health status. The work of the diabetes educator encompasses all four of these areas.

To set standards that make behavioral outcomes in diabetes self-management measurable, AADE identified the AADE7™ Self-Care Behaviors—healthy eating, being active, monitoring, taking medication, problem-solving, reducing risks, and healthy coping. To aid natural communication between patients and the care team, the language of the AADE7 was intentionally designed to be patient-friendly and clinically accurate.

As essential members of a diabetes care team, diabetes educators are skilled in both the delivery of knowledge and in the interventions that create behavior change. If the American healthcare system is going to combat the diabetes epidemic, healthcare professionals must find alternative ways to deliver information about diabetes, help patients develop critical management skills, provide comprehensive follow-up care, and build relationships between providers and patients. Diabetes educators can assist physicians with these tasks and will prove to be an asset to primary care practices that are striving to improve clinical outcomes and provide quality healthcare to the growing number of people with diabetes.

How Can Diabetes Educators Assist Primary Care Physicians in Improving Patient Outcomes?
Physicians cannot do everything. Diabetes is a complex disease requiring a high level of care from an entire healthcare team. Without a professional support team, primary care practices are often not equipped to deliver the level of care needed for successful health outcomes for patients with diabetes. Diabetes educators have a rightful place on, and an essential role in, the healthcare team, and can help the physicians improve their patients’ outcomes by facilitating the behavior-change process.

AADE asked a group of association leaders, primary care physicians, nurse practitioners, and physician assistants to explore the idea of diabetes educators in primary care offices. When examining the ability of primary care practices to provide comprehensive care to patients with diabetes, the following conclusions were reached:

  • in the primary care office setting there is a lack of time and resources to educate patients with diabetes on how to manage their disease successfully;
  • continuous patient education throughout the disease progression is a challenge for primary care offices;
  • intense and complicated treatments for diabetes require more specialized education and follow-up care, which are difficult to provide in the office setting; and
  • the impact of the patient’s lifestyle needs, cultural influence, physical limitations, and psychological state are often overlooked when treatment recommendations are made.

The group also recognized that:

  • diabetes educators are valuable for their diabetes knowledge, method of education delivery, hands-on experience, team approach, and patient compassion;
  • diabetes educators would be an asset to primary care practices and community-based diabetes education programs; and
  • the team approach to diabetes care will optimize successful patient outcomes over the long term.

It is clear that diabetes educators have a great deal to offer primary care, and it would be beneficial to both providers and patients to incorporate the services of a diabetes educator into primary care offices. Even though there are obstacles to integrating educators into this setting, it will be worth the effort in the future.

With the epidemic rise in diabetes, primary care offices will continue to be flooded with diabetes patients requiring a higher level of care. Now is the time to form relationships with other members of the healthcare team, clearly define each member’s role, identify obstacles that might prevent these long-term partnerships, and begin strategizing solutions.

There is no one-size-fits-all diabetes management plan. Diabetes is as variable as those diagnosed with the disease, and patients need individualized care and personal attention. Diabetes educators have the time, skills, and knowledge to assist physicians with diabetes patient care. The introduction of diabetes educators into primary care and alternative settings will affect diabetes on all levels—the community, the patient, the physician, the healthcare system, and, certainly, the payers. It is time to embrace education as an essential element in diabetes care.■

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