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Overcoming Barriers to Diabetes Education by Bringing It Closer to Home

AADE16 Conference Coverage
What if you had a great diabetes self-management education program (DSME), but people stopped coming? Leaders at the University of Washington (UW) asked themselves that question 6 years ago when it became clear that patients who completed the program had good clinical results, but that too many who started the lessons didn’t finish.

  As Alison Evert, MS, RD, CDE, coordinator of diabetes education programs at UW explained, a patient survey revealed the problem: location, location, location. For many, classes at the academic medical center were too far from home and parking cost too much. “Our status quo didn’t seem to be working anymore,” Evert said.

  From this realization came a solution, which Evert presented with Peggy Odegard, PharmD, CDE, and Maureen Chomko, RD, CDE, in the session, “Closer to Home: Enhancing Access to Diabetes Education via Training Clinic Staff in Primary Care,” at AADE16, the 2016 annual conference of the American Association of Diabetes Educators (AADE).

  Evert and Odegard, who is a professor and associate dean at the UW School of Pharmacy, laid out the 6-part process they used to bring their DSME into primary care practices up to 60 miles away from their base in Seattle. Using a “train the trainer” program, they identified nurses, dietitians, or other key staff within clinical practices who could learn to provide DSME in settings convenient to patients.

  In doing so, they took on the staggering numbers of diabetes care: 29.1 million have the disease and 86 million have prediabetes in the United States,1 but there are fewer than 5500 board-certified endocrinologists2 and only 14,000 members of AADE.3 Yet, doctors can’t fit disease management into an 18-minute office visit. Evert relayed a conversation with an internist, who told her, “I’m afraid to ask an open-ended question. I’ll never get out of the room.”

  Providing DSME when patients are diagnosed—as well as at subsequent critical junctures—is part of the 2015 position statement of the AADE, the American Diabetes Association (ADA), and the Academy of Nutrition and Dietetics.4 As Evert said, the number of patients involved calls for more offerings and more education within primary care; but who in primary care can do this?
  The idea of training professionals to give DSME in the primary care setting isn’t new. Evert pointed out that Melinda Maryniuk, MEd, RD, CDE, of Joslin Diabetes Center pioneered this years ago. For the UW team, however, there were still many steps and barriers to overcome to bring their idea to life.

  Evert said the process begins with identifying key stakeholders. Dietitians in private practice, pharmacists who work collaboratively with primary care physicians, and medical directors of large primary care practices are key. She encouraged these arrangements to be governed by a memorandum of understanding, including how everyone will be paid.

  There are different curriculum choices—AADE and ADA each have programs—but any program must be tailored to the population of the clinic. Next, programs must build a system for referrals to get newly diagnosed patients to classes. Billing is another key issue: the UW team found early on that they were getting paid promptly by Medicaid and Medicare, but not by commercial payers. Insurers may use different codes, Evert warned. Roles in the practice must also be defined, and marketing and reminders to patients are essential.

  Training the Trainers

  Odegard said there’s one more ingredient to success: a practice-based DSME program needs a champion. When selecting who in the practice is right for the DSME role, she is less concerned with credentials and more interested in “Who has the passion and the interest in being part of the team?”

  Although many trainers will be nurses or dietitians, some of them may who have lived with the disease or have a family member with diabetes. Odegard outlined the steps for getting them in front of patients once they are identified. A baseline assessment is essential.

  The UW training starts with a group session, “Diabetes Survival Skills Workshop,” with 7 components: (1) an overview; (2) blood glucose monitoring; (3) targets and hypoglycemia; (4) medications, including oral agents, injectable glucagon-like peptide-1 receptor agonists, and insulin; (5) lifestyle intervention, including nutrition; and (6) how to inject insulin and (7) self-blood glucose monitoring. Odegard said trainers are tested for competency before moving on to individualized training.

  During this phase, trainers are asked to reflect on their strengths and weaknesses and tap the strengths of their individual styles. Trainers practiced teaching lessons to Odegard and Evert, who offered feedback. Odegard and Evert sat in on early sessions in which trainers engaged patients until they were up to speed. Trainers learned that engaging the patients is key.

“An active learning style is really important in DSME,” Odegard said. Trainers also need to be rewarded—the UW network offers an award for its top trainer. One of those trainers is Chomko, who was on the staff at a primary care clinic. “I did not think of myself as a diabetes expert,” she said.

  Tailoring the program to the audience is key, Chomko said. Based on feedback, UW condensed a 10-hour program into 6 hours. Getting feedback from patients as they go through the program allows trainers to make adjustments. The UW program also does an assessment of participants when they start, she said, to understand their struggles, their barriers to care, and their cultural beliefs.

  Results

  Chomko shared data based on patient electronic health records that show attending at least 1 DSME class correlated with a significant reduction of glycated hemoglobin (A1C) after 3 months that was largely sustained at 6 months.

  Overall, an initial group of patients at one clinic saw their average A1C drop from 8.5% to 7.4% at 3 months and remain at 7.8% at 6 months. Patients lost an average of 3.5 pounds at 3 months and 5.2 pounds by 6 months. As expected, “the newly diagnosed patients saw the greatest benefit,” she said. “Those with depression did not have a decreased benefit.”

“It works, and it’s translatable,” Chomko said. Trainers may benefit, too. One trainer who has incorporated lessons into her own life has lost 27 pounds, she added.
References

  1. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/.Updated April 1, 2016. Accessed October 1, 2016.

  2. Owens C. US endocrinologist shortage affects access to care, physician satisfaction. Healio website. http://www.healio.com/endocrinology/diabetes/news/print/endocrine-today/%7B511d7427-678b-42e0-9b7b-4e374fabc62a%7D/us-endocrinologist-shortage-affects-access-to-care-physician-satisfaction. Published May 2011. Accessed October 5, 2016.

  3. About AADE. American Association of Diabetes Educators website. https://www.diabeteseducator.org/about-aade.Accessed October 5, 2016.  

4. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41(4):417-430. doi: 10.1177/0145721715588904.
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