Overcoming Barriers to Diabetes Education by Bringing It Closer to Home

What if you had a great diabetes education program, 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 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. 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 a session, “Closer to Home: Enhancing Access to Diabetes Education via Training Clinic Staff in Primary Care,” part of the 2016 annual meeting of the American Association of Diabetes Educators (AADE).

AADE began Friday and concludes Monday in San Diego, California.

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 diabetes education 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 diabetes self-management education (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, but there are fewer than 5500 board-certified endocrinologists and only 14,000 certified diabetes educators (CDEs). For most patients, diabetes care happens in primary care, yet doctors can’t fit disease management into an 18- minute office visit. As one internist told Evert, “I’m afraid to ask an open-ended question. I’ll never get out of the room.”

Because giving patients DSME when they are diagnosed—not when the disease has progressed—is the official position of the AADE, the American Diabetes Association (ADA), and the Academy of Nutrition and Dietetics, the numbers call for more education within primary care, Evert said. The question is: who 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 year years ago. For the UW team, however, there were still many steps and barriers to overcome to bring their idea to life.

For related coverage, visit our conference page from the 65^th ADA Scientific Sessions.

Evert said the process begins with identifying key stakeholders—dietitians in private practice, pharmacists who work collaboratively with PCPs, 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 a 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 be defined. 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?”

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

The UW training starts with a group session, “Diabetes Survival Skills Workshop,” with 7 components: an overview; blood glucose monitoring, targets, and hypoglycemia; medications including oral agents, injectable GLP-1 agonists, and insulin; lifestyle intervention including nutrition; and how to inject insulin and 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 where trainers engaged patients, until they were up to speed. Trainers learn 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 in to 6 hours. Getting feedback from patients as they go through program allows trainers to make adjustments. The UW program 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 EHRs that show attending at least one DSME class was correlated with a significant reduction of A1C after 3 months, which 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 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.” And, trainers may benefit, too. One trainer who has incorporated lessons into her own life has lost 27 pounds, Chomko said.