The January 2012 issue of Health Affairs has this article promoting the use of non-medical personnel as preferable to medically credentialed personnel because they are less costly. What do you think about this issue?

Title of the article:

"How Effective Were Lifestyle Interventions in Real-World Settings That Were Modeled On the Diabetes Prevention Program"

Authors: 
Mohammed K. Ali (mkali@emory.edu) is an assistant professor of global health at the Rollins School of Public Health, Emory University, in Atlanta, Georgia. Justin Echouffo-Tcheugui is a postdoctoral research fellow at the Rollins School of Public Health, Emory University
,David F. Williamson is a visiting professor at the Rollins School of Public Health, Emory University.

Here are some of the conclusions drawn from their article:
"Sensitivity analyses showed that programs with lay community educators achieved greater weight loss than those with medical and allied health professionals as educators. That finding "has enormous importance for the scalability and economic sustainability of diabetes interventions,"

"We conclude that costs associated with diabetes prevention can be lowered without sacrificing effectiveness, using nonmedical personnel and motivating higher attendance at program sessions."

Reference:

http://content.healthaffairs.org/content/31/1/67.abstract

I promise not to rant on the DPP.

The abstract actually reads "Change in weight was similar regardless of whether the intervention was delivered by clinically trained professionals or lay educators."  And actually, since the DPP often enlisted the YMCA personal as lay educators, it might not be surprising that these people were really good "coaches" who achieved good results.  After all, that is their job at the Y.

It is well known that one doesn't have to be a health care provider to help people lose weight. Look at Weight Watchers. Losing weight is one thing. Keeping it off is another matter.

This is not to say one HAS to be a health care provider to help people keep the weight off, but here is where the real expertise comes in.

So the question is, why market it as diabetes prevention? Why not call these programs what they are? Weight loss programs.

I find this interesting in light of Diabetes Expert Disses Weight-Loss Programs

Thank you!

EnJOY!

Joy 

presentdiabetes.com Contributing Nurse Editor

The problem I have with this sort of thing is that lay people don't have a good understanding of how involved and complex a problem diabetes really is. Thus, they tend to give inaccurate information a lot of the time. For instance, a person not trained to be a diabetes educator might say "if you have diabetes don't eat anything white," or "artificial sweetners raise blood sugar and are just as bad as sugar" or "don't eat this but eat all of this other stuff you want" or "honey doens't raise blood sugar b/c it's natural"... We have heard of all kinds of crazy things that people have heard from the gym trainers and others who "think" they know what they are talking about. These folks need to stick with teaching people exercise (or whatever) and leave diet and diabetes to those who actually know what they are talking about...It's frustrating that everyone thinks that can do nutrition and/or diabetes education. I am not out there trying to misrepresent myself by being a speech therapist or surgeon or medical doctor. I know when to defer the question/problem a patient may have to the appropriately qualified medical professional. But, everybody wants a piece of nutrition and it's frustrating.

Karen Rosato, RD, LD, CDE

I realize that there is a huge concern about protecting the profession of nutritionist, but that is a very parochial view.  The materials for the DPP are very standardized.  I don't see any reason lay educators can't teach this material.

Brian, and all,

To shed more light on the role of HCPs being the preferred DIABETES educators when educating on the CLINICAL aspects of DSME (as opposed to lay community health workers...CHWs...and NOT in the context of weight management), remember this:

Quality standards for both DSME and for diabetes educators have been published by the AADE in a white paper; the standards recommend (I'm paraphasing) that:

1)  CHWs employed by a DSME program MUST complete a standardized initial training program created by the DSME entity to prepare them for the specific job they will do with pts, and complete an annual review training program.

2)  Their job must be NON-CLINICAL in the DSME program; their primary job is to "connect" the diabetes pts with on-going support, problem-solving, medical and education resources in their own neighborhood and work communities that "fit" the patients' own issues, variables and needs (not the least of which are financial and cultural).

3)  Only diabetes educators can perform the CLINICAL aspects of the DSME function.

4)  The diabetes educators are in different experiential and educational "levels" that correspond to what they are assigned to do (e.g., non-CDE educators, CDE educators, BC-ADM educators, etc.)

Thoughts?? 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

I certainly understand, the AADE has been very aggressive in trying to protect the profession.  In this case, this is a class at the YMCA.  It is just some basics, all very prescribed.  You don't have cardiologists getting all out of shape over lay educators discussing cardiovascular health in the exact same setting.  And this is a population which otherwise would not be otherwise served by certified educators.  If the DPP is forced to use of CDEs then it will drive up the costs and may markedly reduce the number of programs/participants.  I don't think that is a good outcome.

Brian, it is not a matter of the AADE trying to protect its own profession. 

It really is, in fact, a matter of preserving the QUALITY of diabetes care.

  
This means, among a myriad of things, assigning the right people to the right job.  
   

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Quality?  Are we even talking about the same thing?  Have you actually read the DPP materials?  These materials are antiquated and just plain substandard.  If you read through them there is not a single word about the relationship between carbohydrates and blood sugar control.  Heck, they don't even suggest you reduce sugar.  I have a real hard time believing that this is about quality.  If it were really about quality, the AADE would seek to improve the DPP instead of suggesting that only "certified educators" should echo a message that is more than 15 years old and based on flawed nutrition advice.

And if we go back to the original topic, lay educators were found to get results just as good as certified educators.  How is that not quality?

The orginal title of the this thread was the "trend" emerging in the use of non-medical personel for diabetes education. That means use of non-medical non certified, non professionals are being used more than in just this instance.  DPP doesn't seem to address all the things that our ADA certified program teaches and this is only one example of lay people used in this fashion. It is very basic and thus I believe a "lay person" can "teach" this material. However, the information covered in a real diabetes education class taught by CDEs is going to be much more indepth than DPP. I feel that certain people attending a program such as DPP may have questions not answered by DPP cirriculum and the potential for a lay person to give out misinformation is great when posed with more complex questions. I don't care if the DPP is taught by a CDE or not. I think a more thorough program to address prevention could be developed. DPP is barely scratching the surface. However, if DPP showed some positive results, great. I am not bothered by that in the least. However, DPP and and ADA certified program are not the same thing. I wonder why Brian you feel such animosity toward the profession of dietetics and diabetes education? Or, maybe I am getting the wrong impression?

Karen Rosato, RD, LD, CDE

If community health workers can reach people about improving their health then I say go for it!  We have recently hired a community health worker as part of an grant project here and I have to say that she has been reaching the African American community in ways that we were unable to before she came here.  I figure there is plenty of diabetes to go around and we need all the help we can get.  My main concern is that those people who have additional problems will be referred to a professional as needed.   

I have to say that every dietician and CDE I have ever met has been a caring person trying to really help us diabetics.  But as a patient, I have serious concerns about the AADE efforts to monopolize the setting the public health policy and provision of services.  I consider those actions to be harmful.  These are the actions of a trade or labor union, not a professional society.  Until there is better competency in the establishment of these public health positions I am totally against the consolidation of control.  I frankly see little difference in the dangerous advice of "honey doens't raise blood sugar b/c it's natural" and the outright failure of the DPP materials to even mention that carbs raise blood sugars.

I do agree it is important to establish levels of quality and I have no disagreement with the certification of educators.  But there is a great need to have education be available at many levels and until there is greater clarity about appropriate public health position in areas like nutrition it is premature to stifle the ability of different professions to offer a variety of servces.

Here in Vermont we're using the Healthy Living Workshop developed by Stanford  http://patienteducation.stanford.edu/  as a way to help folks with chronic diseases learn how to manage their life. We now have diabetes-specific healthy living workshops that are also peer-led. Some info is here:  http://hcr.vermont.gov/sites/hcr/files/Microsoft%20Word%20-%20Diabetes%20Overview.pdf

There's been a lot of discussion in our local AADE chapter about the role of the healthy living workshop and peer leaders. We've come to the conclusion that health professionals are the best folks to teach the specifics of diabetes. However, there aren't a lot of us, our programs can be expensive, and often we're not easy for everyone to access. The healthy living workshops are small groups held in the community in an easily accessible location. We offer these groups throughout the state, and because they're peer-led they have a much lower financial cost.

I've had several of my clients attend the healthy living workshop, and in fact I recommend them all the time. Just this week I encouraged one person with T2 to attend he next workshop. She's been through our diabetes education program and has seen us several times individually. She knows what to do, and she understands diabetes. Yet she's honest that she's having trouble putting all of this knowledge into practice. That's one place where the healthy living workshop can play a role - she will learn from her peers.

In my mind, combining the expertise of health clinicians with the experience of people living with a chronic condition is a recipe for success.

All -

Very interesting dialogue on this topic! It is an interesting topic to discuss as we in the U.S. and around the world attempt to tame the curve of the rising rates of prediabetes and type 2 diabetes. No doubt many people with a variety of skills and talents will need to be put to work to help people and society change eating habits, their food choices, activity patterns and the whole notion around preventing diseases rather than waiting for treatment once they happen.

Community health workers who are trained and supervised by healthcare providers expert in diabetes have been and continue to be shown to be effective at implementing programs with positive outcomes. Much data has been collected beyond the DPP study itself and the continuing DPPOS. A wide variety of models have and are being studied and implemented. The CDC program is just one.

There was mention of an article in Health Affairs, Jan 2012. Not only is there an article about diabetes prevention but the entire issue is dedicated to diabetes. I have ordered my self a copy of the issue for about $40 b/c it looks like something I want to have to read and in my files.

The following is a nice recap of the CDC's efforts on implementing the National Diabetes Prevention Program under the Affordable Care Act.

The National Diabetes Prevention Program is made up of four components. Each is necessary for the success of the program.

• Training. Train the workforce that can implement the program cost effectively.
• Program Recognition. Implement a recognition program that will assure quality, may lead to program reimbursement, and allow CDC to provide a registry that will report program outcomes.
• Intervention Sites. Develop intervention sites that will build infrastructure and provide the lifestyle intervention.
• Health Marketing. Increase referrals to and use of the lifestyle intervention.

Read more about NDPP at: http://www.cdc.gov/diabetes/prevention/about.htm

Brian made a couple of comments along the way that I want to address:

Low carbohydrate: We are well aware of your notions about lower carbohydrate eating plans and people with diabetes. You note that the DPP and NDPP doesn't promote low carb and for this reason they're curriculum is not correct/worth following. The DPP research and much research in people with diabetes as well as healthy eating shows the benefit of eating a moderate to high intake of carbohydrate (45-65%) of calories. The DPP research clearly showed that what is most important in people achieving weight loss (5-7%) and keeping whatever of that weight loss off possible is a calorie control, lower fat (30% or less) intake coupled with at least 150 minutes of physical activity/week and ONGOING SUPPORT. In fact, the Feb issue of Diabetes Care will contain an extensive systematic review on carbohydrate, protein and fat in diabetes management.I had the pleasure of being a reviewer.

AADE/Diabetes Educators: I respond here also as a member of the AADE Board of Directorsm 2011-2014. First, AADE is not the credentialling body for CDEs - National Certification Board for Diabetes Educators is. AADE is working hard at defining and delineating various levels of expertise for diabetes education and lay health workers. I encourage people to review several recently published AADE position statements on these topics: http://www.diabeteseducator.org/ProfessionalResources/position/

AADE is also working hard to get credentialled diabetes educators (CDE or BC-ADM) able to be directly reimbursed by Medicare as the locations for the delivery of diabetes education change and evolve including in primary care offices, free standing offices and using telehealth. AADE has quickly grown the number of accredited diabetes education program to over 400. 

AADE is working on state licensure efforts. As the Affordable Care Act is put into place and as Medicare writes regulations to implement this and quide HCPs it is becoming clear that diabetes educators should be licensed and this must be done at a state level.

I'm open to comments on any or all of the above.

Thanks,
Hope Warshaw, MMSc, RD, CDE
Nutrition Section Editor, PRESENTdiabetes.com

Hi Hope

First of all, thank you for all the good work you do for AADE. I just reviewed the AADE statement that you recommended an noted that there are various levels of diabetes educators recognized by AADE with level 4 and 5 being the credentialed Diabetes Educators. Knowing how the health care system is going, it seems quite possible that funding for the credentialed CDE will disappear and the use of non-credentialed diabetes educators will be found to be more cost effective.

Pat -

I think there will be plenty of jobs for credentialed diabetes educators for some time to come with our population of people with prediabetes and diabetes. Don't give up the ship!!

But I do believe it will be important for credentialed diabetes educators to transition our roles to assist people and their providers more with diabetes management, progression of therapy based on approved algorithms. In other words going beyond teaching diabetes self-management in DSMT programs.

I also believe that credentialed educators will be useful and put to work in programs using a chronic care model of disease management. We need to learn and practice coaching strategies and skills to help people make the behavior changes necessary to make clinically and cost effective improvements in their diabetes care.

Let's hope for the best and keep honing our skills and talents!

Hope Warshaw, MMSc, RD, CDE
Nutrition Section Editor, PRESENTdiabetes.com

I think you have a very valed point.  CDSMP  (Stanford) offers a verbatim curriculum.  What I have heard offered from general public during a health screening is scarry.   At least in a structured curriculum, all of are meeting our needs- less to no cost for the person with diabetes, no strain on the health care system, great support and proven good outcomes and ACCURATE information. 

 CDSMP  (Stanford) chronic disease self-management courses-for asthma, HIV, Diabetes are offered both online and as seminars. The seminars are offered in Spanish as well.

As I see diabetes education programs closing in my area, there's a real fear that CDEs are too expensive for hospitals to employ. However, once the programs close folks with diabetes find that they can't access quality education, and physicians realize the important role that CDEs play. Some of the hospitals that closed their diabetes programs are now gradually reinstating some type of diabetes education, usually a combination of group classes and community programs.

Here's my take:  given the fact that health care costs continue to rise, and that the incidence of diabetes is also rising, we're going to come to a crunch point. We need to provide quality self-management education in a low cost way and that means continuing to utilize the expertise of CDEs but perhaps in a different role. Instead of directly providing education we may be managing community workers who fill that role.  But in order to keep a place at the table, we need to be directly involved in planning the changes that are bound to take place. If we let others take over the planning and don't maintain a strong voice at the table, we are going to be left out.