Reexamining the Roles of Diabetes Educators

The role of the diabetes educator is very different from what it was 5 years ago, Linda Siminerio, RN, PhD, CDE, associate professor of medicine, University of Pittsburgh, executive director, University of Pittsburgh Diabetes Institute, told attendees of the “Healthcare Delivery is Changing: Where Do Diabetes Educators Fit?” symposium at the 72nd Scientific Sessions of the American Diabetes Association. With medical reform on the horizon and new educational initiatives being implemented for patients discharged to home after hospitalization, she predicted that more changes will come for diabetes educators.

A common theme throughout the annual meeting was that effective diabetes self-management plays a critical role in positive outcomes. Patient self-care is

becoming even more important as the numbers of people at risk for and diagnosed with diabetes increases while the number of physicians providing diabetes care wanes. Dr Siminerio calls for expansion of the roles of educators, nurses, pharmacists, and dieticians to the maximum allowed by licensing to help assuage the problem. With respect to diabetes care, diabetes educator support of patient self-management may be one of the most important roles these health professionals can play.

During a presentation titled “Can Patients Be Activated to Improve Self-Management Behavior?,” Jessica Greene, PhD, associate professor, department of planning, public policy, and management, University of Oregon, talked about patient activation, how it is measured, and how diabetes educators can use it to individualize diabetes education strategies and facilitate patient self-management. Dr Greene discussed that by paying attention to patient activation, diabetes educators may improve outcomes and subsequently contain costs.

Patients who are activated are considered to have knowledge and skills competency for managing their own health. The extent of patient activation can be quantified with the patient activation measure (PAM).¹ PAM activation levels range from 1 to 4, with 1 being the lowest and 4 being the highest.

Patient activation is related to diabetes- related health outcomes and cost in cross-sectional studies, and in several intervention studies. Specifically, higher PAM levels were associated with certain healthy behaviors (eg, in physical activity and eating fruits and vegetables); appropriate use of healthcare; active chronic care self-management (eg, regular examinations for people with diabetes, keeping a diary of blood pressure readings); and better control of chronic conditions (eg, A1C reduction, fewer hospitalizations).² PAM predicted utilization and health outcomes 2 years into the future for patients with diabetes.³ PAM is not only related to health outcomes, but to costs as well. A small number of long-term and prospective studies suggest patient activation can be increased and those increases are related to improvements in quality outcomes.

Not surprisingly, studies show that PAM levels vary from patient to patient. “Many of the behaviors we are asking people to do to self-manage chronic conditions are only done by those at the highest level of activation,” said Dr Greene. Patients with lower activation levels become discouraged and overwhelmed when asked to take on the more complex and difficult behaviors. “If we start with behaviors more feasible for patients to take on, it has the potential to increase their ability to experience success,” she explained. She suggests using activation levels to determine realistic next steps for individuals to take.

Dr Greene presented results from one study that supported the tailoredcoaching approach.⁴ Compared with a group receiving usual care, patients who received self-management coaching based on their level of activation had greater improvements over a 6-month period in: PAM, diastolic blood pressure, low-density lipoprotein cholesterol, medication adherence, reduced hospitalizations, and use of the emergency department (Figure). Dr Greene concluded, “Diabetes educators are well poised to improve patients’ levels of activation, through tailoring education to patient activation and supporting skill development.”

In a presentation titled “Should Diabetes Educators Be Care Managers in Primary Care?,” Nadine Tomaino, RN, Med, CDE, practice-based care manager, University of Pittsburgh Medical Center (UPMC) Health Plan, talked about her experience as a diabetes educator in a patient-centered medical home (PCMH). Ms Tomaino spent the early part of her career working as a diabetes educator in a small community hospital. Now she functions as a practice-based care manager for the UPMC Health Plan. UPMC first started to realize the tremendous value of having certified diabetes educators (CDEs) in its physician practices about a decade ago. Since then, the UPMC Health Plan has steadily expanded the role to encompass practicebased case management. In 2010, UPMC Health Plan hired 27 practice-based nurse care managers at 44 of its physician practices. Continued expansion is planned throughout 2012. Currently, 2 full-time diabetes educators are employed to support 65 practice-based case managers. “We need to use our specialist CDEs strategically,” stated Ms Tomaino.

The chronic care/PCMH model gained attention in 2007. It incorporates 7 important principles: (1) personal physician point of contact, (2) physiciandirected practice with a team leader, (3) whole-person orientation, (4) case management imbedded into practice, (5) coordinated and integrated care, (6) quality and safety, and (7) enhanced access to care.

“I have a number of tools available to me now within the practice that I did not have when I worked at a small community hospital education program,” shared Ms Tomaino. For example, she now has direct access to physicians; electronic medical records; a database; patient claims data; medicine refill information; and alerts for overdue tests, physician visits, preventative screening, and admissions and discharges from hospital and emergency departments.

UPMC Health Plan data suggest that diabetes outcomes and cost benefits within its PCMH practices are better than those of the non-PCMH practices. Compared with non-PCMH practices, member medical costs decreased 4% (even with additional primary care physician office visits) and hospital readmissions decreased 13% among the PCMH practices from 2008 to 2009.

Ms Tomaino believes the keys to integrating successful self-management education into the PCMH are to have a motivated medical health system champion, as well as an active and engaged health team. Additionally, patients must be followed closely throughout every system of care. Barriers that prevent patient self-management should

be addressed and educators need to think outside the box about how to deliver education in primary care and gain better access to patients. For example, she suggests asking, “How can I see this patient that never comes in? How can I get outside the practice to help this patient?” In her practice, this type of help may come with links to transportation services or social work.

Funding Source: None.

Author Disclosure: The author reports receiving payment for involvement in the preparation of this manuscript with no associated conflicts of interest.

Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.1. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4, pt 1):1005-1026.

2. Dixon A, Hibbard J, Tusler M. How do people with different levels of activation self-manage their chronic conditions? Patient. 2009;2(4): 257-268.

3. Remmers C, Hibbard J, Mosen DM, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32(4):320-327.

4. Hibbard JH, Greene J, Tusler M. Improving the outcomes of disease management by tailoring care to the patient’s level of activation. Am J Manag Care. 2009;15(6):353-360.

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