February 25, 2013

National Standards for DSME and DSMS – Part 4

Part 4 of 6 Parts

The sixth standard states, “A written curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, will serve as the framework for the provision of DSME. The needs of the individual participant will determine which parts of the curriculum will be provided to that individual.”

Here again, the door is wide open for discrimination. CDEs are nefarious for deciding that individuals don't need some part of training when a mandate will work just fine. This means that the patient with diabetes is not taught something or possibly a key that is necessary in the self-management of diabetes. If the patient cannot figure out from the mandate what needs to be accomplished and why, they are left in the dark and wondering what they missed. I know this by the questions I receive in emails. People with type 2 diabetes are asking why is this so important or is this really necessary. You can bet I ask if they have had any time with a CDE. No all have, but those that have had time with a CDE, say they were told to do it with no explanation.

Another part of this that makes me wonder at the training of CDEs is the number of times people ask questions that should have been covered in an assessment. The time I had an individual say they had just seen a CDE and the question was what do I do now. He had asked the CDE what to do for depression as he was feeling very low and in addition to just having a diagnosis of diabetes, the previous week he had buried his wife of 46 years. His question was not answered and the session was ended without any indication that the CDE would talk to his doctor or anyone. As he said in his email – it was as if she could not get out the door fast enough.

Even my suggestion to call his doctor did not get him any help and it took almost two weeks to find someone he could talk with and actually give him the help he needed. He was doubly blessed that the person he got set up with also had type 2 diabetes and knew what he was talking about.

Why the next section is talked about really has me wondering, especially since most people with diabetes are not being serviced by CDEs and the people with prediabetes are not seen by CDEs. Yes, a very few have consulted with CDEs if they are a relative or close friend of the family. I even had one of these people email me telling me that they had been educated by a CDE, but they refused to answer the question of how close they were related or if they were a friend of the family.

“Individuals with prediabetes and diabetes and their families and caregivers have much to learn to become effective self-managers of their condition. DSME can provide this education via an up-to-date, evidence-based, and flexible curriculum.”

The following core topics are commonly part of the curriculum taught in comprehensive programs that have demonstrated successful outcomes:
1. Describing the diabetes disease process and treatment options
2. Incorporating nutritional management into lifestyle
3. Incorporating physical activity into lifestyle
4. Using medication(s) safely and for maximum therapeutic effectiveness
5. Monitoring blood glucose and other parameters and interpreting and using the results for self-management decision making
6. Preventing, detecting, and treating acute complications
7. Preventing, detecting, and treating chronic complications
8. Developing personal strategies to address psychosocial issues and concerns
9. Developing personal strategies to promote health and behavior change”

The above areas are important and should be part of the content in a carefully planned program, but unless an assessment is performed and the program adapted to the individual, the curriculum may miss the target and not be absorbed by the individual. When a proper assessment is done and the approaches to education are interactive and patient centered, then it should be effective. Also necessary is the development of action-oriented behavioral goals that are creative and experienced based in delivery methods are effective. This should indicate that mandates are not effective, but they are too often used.

The seventh standard states, “The diabetes self-management, education, and support needs of each participant will be assessed by one or more instructors. The participant and instructor(s) will then together develop an individualized education and support plan focused on behavior change.”

The idea of individualized education is the key to this standard. This could or should be what every CDE strives for in the education. This seldom is the case because no assessment is done and the education is handed out almost willie-nillie based on the CDEs attempt to hurry through the education. Because the assessment is also a key to giving education on an individualized basis, I am quoting what is important in an assessment.

The assessment process is used to identify what those needs are and to facilitate the selection of appropriate educational and behavioral interventions and self-management support strategies, guided by evidence. The assessment must garner information about the individual’s medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, diabetes self-management skills and behaviors, emotional response to diabetes, readiness to learn, literacy level (including health literacy and numeracy), physical limitations, family support, and financial status. The education and support plan that the participant and instructor(s) develop will be rooted in evidence-based approaches to effective health communication and education while taking into consideration participant barriers, abilities, and expectations.”

The assessment and education plan, interventions, and outcomes must be documented in the patient’s records. This will facilitate and provide assistance to others on the patient's healthcare team and increase the likelihood that all the members will work in collaboration. This will create an atmosphere of learning and success for the patient resulting in improved quality of care.

This information is from the National Standards for DSME and DSMS.

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