What Is the Future of the AADE?

Is there a future for the American Association of Diabetes Educators (AADE)? Not if the Academy of Certified Diabetes Educators (ACDE) has anything to say about it. At present they both have members that have taken the test given by the National Certification Board for Diabetes Educators (NCBDE) and passed it. The ACDE is taking the exclusive route and not allowing honorary membership and is lobbying hard in some states to prohibit anyone with knowledge of diabetes from passing this on to other people with diabetes. This includes peer-to-peer diabetes workers, peer diabetes mentors, diabetes coaches, and others.

The AADE does have honorary members and does unofficially work with a few of the groups in the last sentence above. And the AADE does not list all that have passed the NCBDE examination as members. The about 13,000 members does become more realistic when you consider those that have retired or are not doing certified diabetes education work. Although neither organization is particularly transparent in their actions, from my observations the AADE is the more transparent of the two.

Now I will take a blog by one of theAADE members posted on the AADE website and discuss the points made in the blog. You may read the points here.

“•We should keep moving forward with our public awareness campaign to increase media exposure highlighting what we do for people with diabetes (PWD). Rather than relying on a healthcare provider to recommend diabetes self-management education and support (DSME/S), let PWD know about what we do so they can ask for a referral (similar to what patients do regarding medications after they read or hear about something new).”

False advertising is not what they should be doing. This is the aim of Big Pharma in their advertising and the hypochondriacs answer the call. There has to be some reason that healthcare providers stop referring diabetes patients to CDEs. I know some doctors do not like the conflicts created by CDEs and this is why many will no longer refer diabetes patients. In other more rural areas, CDEs are just not available. When CDEs teach to the lowest level, make mandates the rule and do little actual education, then we must wonder if they have a purpose. Even many studies find that peer-to-peer education produces better A1cs.

“•When considering the value of diabetes education/educators, recognition should be given to what we prevent including the onset of diabetes, complications from diabetes, and costs (i.e., to prevent hospital admissions).”

Oh, if only this last could be true! The CDEs generally do not work with people with pre-diabetes or counsel them. Very few ever work with type 2 diabetes patients; therefore, I have to wonder with so few CDEs, how can we depend on these people to really fulfill the needs of so many. Most CDEs do not properly assess persons with diabetes (PWD). For many it is a one-size-fits-all or nothing. Many will not work with a PWD that talks about depression and most avoid dealing with depression or burnout. How can patients trust CDEs that avoid something like mild depression.

“•Diabetes education should be at the beginning of the algorithm for care of a person with diabetes; not at the middle or end when problems could have already occurred.”

The above is true, but there are not enough CDEs to take this on. Most will not work with telemedicine or groups of patients.

“•Diabetes educators are key providers in chronic care; we should brand our profession to be included in the chronic care model.”

Diabetes is a chronic illness, but with the few CDEs, how can we depend on CDEs to fill this role. Mandates do not work for people with diabetes and we need individual treatment, not the one-size-fits-all treatment they dish out.

“•Diabetes educators need to be armed with more knowledge on the business of diabetes to help us in the current medical care environment (i.e., Patient-Centered Medical Homes, Accountable Care Organizations, etc.).”

Many CDEs are learning that doctors are excluding them from the new medical care environment because of their attitudes.

“•We need to get legislators on our side to push through legislation that will help us in our work with PWD.”

This statement can be taken several ways and is open for interpretation. We have one organization doing this now and we don't need another organization trying to criminalize people for helping others with diabetes.

“•Diabetes educators can collaborate with more money-generating pieces of medical care so we can give quality care to PWD in a team approach (rather than struggling financially on our own and being considered a money-losing part of care).”

They do have a lot to learn.

“•We should clarify the levels of the diabetes educator so it is understood by us, healthcare providers, and the public.”

What levels are they talking about? The levels of mandates, maybe. Or those that run from people with depression? Now if they have different levels of education and training, maybe we should know this.

“•Many people with prediabetes may not appreciate the importance of behavior change to prevent the onset of type 2 diabetes. Perhaps prediabetes should be renamed Stage 1 diabetes to increase the importance of the condition and changes that can be made to prevent progression to DM (Stage 2 diabetes).”

This is one point I could support.

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“•We should look for ways to influence the prevention of type 2 diabetes, from children to adults, with methods that can be accessed by all in need (including those with socio-economic challenges).”

No comments.

“•Electronic medical records give challenge and benefit. Diabetes educators should be at the table during the creation of EMRs to improve ease of use and beneficial data output.”

They are a way behind on this one. EMRs have already been created and are being updated all the time.

“•There are not enough diabetes educators to meet the needs of all PWD that could benefit from DSME/S. We need to get the word out about diabetes education in academic programs and to current healthcare providers that might be interested in becoming diabetes educators. At the same time, we need to increase the public’s knowledge of how we can help, increasing referrals to prevent closing of programs (and back to the knowledge about the business of DSME/S).”

The first sentence is correct, and the rest is a pipe dream as some are interested until they find out about the test and the qualifications needed.

DSME and DSMS to Assist Diabetes Patients

The subject of diabetes self-management education (DSME) of 2011, and 2012 has taken on a companion in the guidelines for 2013. It is diabetes self-management support (DSMS) and this has been the subject of the last six blogs. This is an interesting change and I suspect that this is a change happening because of the shortage of diabetes educators and the ballooning numbers of patients with diabetes. This discussion is found in section F of the Standards of Medical Care in Diabetes—2013. Go to “Navigate This Article” in the second column and then down to “D” which will take you to Pharmacological and overall approaches to treatment, and then page down to “F. Diabetes self-management education and support”

This could be a two edged sword for the ADA when the physician shortage happens. There will be a shortage of physicians to diagnosis and treat diabetes and a shortage of CDE's. They help a minority of type 2 patients now and there is a greater need for more education now.

It will be interesting now that the National Standards for Diabetes Self-Management Education and Support has been updated, to see if there is actually any increase in the education received by diabetes patients or if the situation continues as is or even decreases. This is just another reason for finding ways of bringing more patients with diabetes into training to assist other patients. Research has proven this works and often with better results than professionals.

Since this should be important for every patient to know and be able to know whether their doctor follows the ADA guidelines, I am quoting the recommendations:

“Recommendations

1. People with diabetes should receive DSME and diabetes self-management support (DSMS) according to National Standards for Diabetes Self-Management Education and Support when their diabetes is diagnosed and as needed thereafter.

Nice of them to say this, but even CDEs don't want to teach people with type 2 diabetes when they can spend all their time with type 1's. Read the first comment to this blog by Bennet at YDMV. Rather revealing.

2. Effective self-management and quality of life are the key outcomes of DSME and DSMS and should be measured and monitored as part of care.

This is what should happen. Unfortunately, until the rules are changed, it isn't going to happen.

3. DSME and DSMS should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes.

At least I must give them credit for trying, but the CDEs are not qualified to deal with depression and emotional well-being.

4. DSME and DSMS programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the onset of diabetes.

With the shortage of CDEs, don't expect any help for people with prediabetes. If the Centers for Medicare and Medicaid Services (CMS) continue to promote prevention, maybe another group will be able to move into this void and provide the help and education these people need.

5. Because DSME and DSMS can result in cost-savings and improved outcomes, DSME and DSMS should be adequately reimbursed by third-party payers.”

We know that many physicians in endocrinology are attempting to follow these guidelines when they have certified diabetes educators (CDEs) available, but some just don't have CDEs available. Most doctors outside the diabetes clinics are not following this and won't because of conflicts with CDEs. Others just don't have them available in many rural areas of the country. Therefore, this points out the need for other measures and methods that are necessary for people to educate themselves about diabetes. And then there may be a place for peer-to-peer workers and peer mentors that have received some training. Somebody needs to fill the holes that the CDEs can't be bothered with.

National Standards for DSME and DSMS - Part 6

Part 6 of 6 Parts

The standards are very well thought out in general and I can support them. There are several areas that need emphasis. The first is, “In the course of its work on the Standards, the Task Force identified areas in which there is currently an insufficient amount of research. In particular, there are three areas in which the Task Force recommends additional research:

1. What is the influence of organizational structure on the effectiveness of the provision of DSME and DSMS?

2. What is the impact of using a structured curriculum in DSME?

3. What training should be required for those community, lay, or peer workers without training in health or diabetes who are to participate in the provision of DSME and to provide DSMS?”

I mentioned this in Part 1, and I will cover more of this now. If you have not read the standards yet, please consider doing so. These were published back in September of 2012, but not on the ADA site until January 2013. This is the better read as it can take you to each standard, it has links to research papers, and the AADE website is a download of a PDF file and no active links to research papers. As of this writing, the American Association of Diabetes Educators (AADE) has not seen it necessary to correct prior publications or update those on the books for 2013. The AADE has written about their goals for 2013 to 2015, but did not mention anything about the national standards. This may be read by downloading a PDF file at this link, named the 2013-2015 AADE Strategic Plan.

This plan is mainly a generalization of self improvement for those already in the educator field and some general ideas for expansion. This means keeping their control of the educator field and not bringing in lay people to assist them in any way. With the continued shortage of CDEs, how is this any help to the expanding number of people diagnosed every day with diabetes.

I doubt there is any structured curriculum for DSME and what may exist is still thought of as DSME and DSMT. There is nothing presently for DSMS. In attempting to follow discussions and locate DSMS information, you will need to read DSMT (diabetes self-management training).

If you are looking for information on community, lay, or peer workers without training in health or diabetes who are to participate in the provision of DSME and to provide DSMS, you will not find anything. This is only on the books in the American Diabetes Association link above and as of yet, the AADE has rejected publishing any material about it.

What ever strengths or weaknesses exist in the current standards will need to wait until the next Task Force is activated in probably the fall of 2016. If the new regulations put forth by the Affordable Care Act create unforeseen problems for the ADA and AADE then we might see it happening sooner. The past Task Force was activated in the fall of 2011 and most of the material made public in September of 2012. Final publication did not happen until January of 2013 for most material.

“Members of the Task Force included experts from the areas of public health, underserved populations including rural primary care and other rural health services, individual practices, large urban specialty practices, and urban hospitals.” It is good to see that the underserved populations were included; however, I think that the elderly were not part of this underserved group. The following two paragraphs are important enough to quote as they do mark a point of change and an extremely large area that the AADE may not be able to meet.

“The Task Force made the decision to change the name of the Standards from the National Standards for Diabetes Self-Management Education to the National Standards for Diabetes Self-Management Education and Support. This name change is intended to codify the significance of ongoing support for people with diabetes and those at risk for developing the disease, particularly to encourage behavior change, the maintenance of healthy diabetes-related behaviors, and to address psychosocial concerns. Given that self-management does not stop when a patient leaves the educator’s office, self-management support must be an ongoing process.”

“Although the term “diabetes” is used predominantly, the Standards should also be understood to apply to the education and support of people with prediabetes. Currently, there are significant barriers to the provision of education and support to those with prediabetes. And yet, the strategies for supporting successful behavior change and the healthy behaviors recommended for people with prediabetes are largely identical to those for individuals with diabetes. As barriers to care are overcome, providers of DSME and diabetes self-management support (DSMS), given their training and experience, are particularly well equipped to assist individuals with prediabetes in developing and maintaining behaviors that can prevent or delay the onset of diabetes.”

The last paragraph before the definitions covers something many CDEs may not want, but is important. It is the risk for comorbidities (that is – heart disease, lipid abnormalities, nerve damage, hypertension, and depression) and other medical problems that may affect or interfere with self-care. What I find most intriguing is this statement - “The Standards encourage providers of DSME and DSMS to address the entire panorama of each participant’s clinical profile.” These may be some of the areas many CDEs are least comfortable and will not be able to use mandates to bypass.

This is where these standards become important for the patient to learn and be somewhat knowledgeable about to hold CDEs to providing high-quality education and support.

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

National Standards for DSME and DSMS - Part 5

Part 5 of 6 Parts

The eighth standard states, “The participant and instructor(s) will together develop a personalized follow-up plan for ongoing self-management support. The participant’s outcomes and goals and the plan for ongoing self-management support will be communicated to other members of the health care team.”

If the seventh standard is not completed, chances are this standard will go by the way also. The setting of goals is important for the patient and knowledge of the goals is also important for the healthcare team. This helps communications and lets all members of the healthcare team know what the others are working on. While DSME can be effective for short periods of time, it needs DSMS to reinforce the information and help the patient understand the importance of daily management away from the clinic or doctor's office.

While the primary responsibility for diabetes education belongs to the provider(s) of DSME, participants benefit by receiving reinforcement of content and behavioral goals from their entire health care team. It should not matter that the support (DSMS) comes from the trained peers, community health workers, or community-based programs. Because self-management takes place in participants’ daily lives and not in clinical or educational settings, patients should be assisted to formulate a plan to find community-based resources that may support their ongoing diabetes self-management.

Hopefully, DSME and DSMS providers will work with participants to identify such services and, when possible, track those that have been effective with patients, communicating with providers of community-based resources in order to better integrate them into patients’ overall care and ongoing support. This will be especially important in many rural areas where CDEs are in short supply and are not present on an every day basis.

The ninth standard states, “The provider(s) of DSME and DSMS will monitor whether participants are achieving their personal diabetes self-management goals and other outcome(s) as a way to evaluate the effectiveness of the educational intervention(s), using appropriate measurement techniques.”

For diabetes self-management to become the contributor to long-term, positive outcomes, the provider(s) of DSME and DSMS will need to assess each patient's personal self-management goals and the progress in achieving these goals. At least the AADE has their AADE7 list (found here) that outlines seven behavior changes that everyone needs to consider how they apply to them individually. Differences in behaviors, health beliefs, and culture as well as their emotional response to diabetes can have a significant impact on how participants understand and view their illness and engage in self-management. DSME providers who account for (properly assess) these differences when collaborating with participants on the design of personalized DSME or DSMS programs can improve participant outcomes.

Although this is not feasible yet, for people in rural areas may benefit in the future from telemedicine. At present, assessments of patients may be difficult in rural areas, but attempts must still be made. In some areas, guidelines from professional organizations or government agencies may prevail for time frames of this assessment.

The tenth standard states, “The provider(s) of DSME will measure the effectiveness of the education and support and look for ways to improve any identified gaps in services or service quality using a systematic review of process and outcome data.”

This could be a most important standard if this could be reviewed by a third party, but having a CDE review this is like letting the fox guard the chicken coop. Will the CDE be responsible? Will new advances in knowledge, treatment strategies, education strategies, psychosocial interventions, and the changing healthcare environment be incorporated into the ongoing education and support? If they are responsible, they will identify areas of improvement and make the necessary adjustments.

This should be in their mind at all times. “The Institute for Healthcare Improvement suggests three fundamental questions that should be answered by an improvement process:

1. What are we trying to accomplish?

2. How will we know a change is an improvement?

3. What changes can we make that will result in an improvement?

Once areas for improvement are identified, the DSME provider (CDE) must designate time lines and important milestones including data collection, analysis, and presentation of results. Process measures are often targeted to those processes that typically impact the most important outcomes and these must be properly assessed.

If you have read the standards, you should agree that this is putting a lot on the plate for the AADE and their CDEs. Unless they change their way of doing business, these standards will not become a reality for many people with diabetes and the people with prediabetes will continue to be ignored.

To this point, I have not mentioned the shortcomings of the ADA 2013 Guidelines. I can see many things left out of the ADA Guidelines that may impact the National Standards for Diabetes Self-Management Education and Support.

First, the ADA Guidelines totally ignore any mention of telemedicine, which could be an advantage for CDEs providing education and support for rural patients with diabetes. Second, while the group of patients who are at risk for diabetes are mentioned and some overall guidance is mentioned, this group of people need a name more descriptive than prediabetes and specific treatments need to be part of the guidelines. This could make it possible for the CDEs to be reimbursed for time spent on education in this group of patients. Under current ADA guidelines, reimbursements are very difficult for time spent on education, which discourages CDEs from even attempting education for this group.

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

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.

National Standards for DSME and DSMS – Part 3

The fourth standard states, “A coordinator will be designated to oversee the DSME program. The coordinator will have oversight responsibility for the planning, implementation, and evaluation of education services.”

This works well in larger cities where two or more certified diabetes educators (CDEs) work for the same office, however, I do have to wonder about CDEs working alone in some of the smaller offices, clinics, and hospitals. As the DSME continues to evolve, the coordinator should play a pivotal role in ensuring accountability and continuity in the education program. Will coordinators need to travel from large offices to smaller offices and rural areas as an area coordinator? This is something to be considered. The standard does state, in some cases, particularly in small practices, the coordinator may also provide DSME and/or DSMS.

The fifth standard states, “One or more instructors will provide DSME and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE or BC-ADM. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes and with supervision and support.”

Maybe historically, nurses and dietitians were the main providers of diabetes education, but in recent years, this has been expanded to mainly pharmacists. It is therefore natural to see this in the hierarchy of people in the literature and whom they assign the functions of the different standards to for completion. At least the obligatory continuing education is included as a way of segregation to keep lay people on the sidelines.

The next area seems an attempt to make everyone welcome, but remember it is only the CDEs that can supervise and monitor the education and support. This means fewer CDEs doing actual DSME and DSMS. A number of studies have shown that a multidisciplinary team approach to diabetes care, education, and support works well for the patient. Yet in too many cases, the patient is often not the center of the efforts and central to the team approach.

“The disciplines that may be involved include, but are not limited to, physicians, psychologists and other mental health specialists, physical activity specialists (including physical therapists, occupational therapists, and exercise physiologists), optometrists, and podiatrists. More recently, health educators (e.g., Certified Health Education Specialists and Certified Medical Assistants), case managers, lay health and community workers, and peer counselors or educators have been shown to contribute effectively as part of the DSME team and in providing DSMS.”

Yes, they do include lay health and community workers plus peer counselors or educators when it is to their advantage. But, notice that a system must be in place that ensures supervision of these lay people. I agree that for questions the lay people do not have answers for need to have professionals available to answer when the questions are beyond their training. This is wise even for the CDEs to have doctors or other professionals available to back them up, but this seems to be an insult to their credentials.

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

National Standards for DSME and DSMS – Part 2

Part 2 of 6 Parts

In this blog, I will start with the standard number one and cover several of them. However, the definitions should be stated first and I will quote them.

DSME (Diabetes Self-Management Education).

“The ongoing process of facilitating the knowledge, skill, and ability necessary for prediabetes and diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.”

It is important to note that prediabetes is mentioned here and no distinction is made to prefer one type of diabetes over another. Yet, this distinction is prevalent in the activities of certified diabetes educators (CDEs) in practice today. This is the reason for calling attention to this.

DSMS (Diabetes Self-Management Support).

“Activities that assist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management training. The type of support provided can be behavioral, educational, psychosocial, or clinical.”

These are the two key definitions that apply to this and several following blogs. Keep them in mind when reading the materials.

The first standard states, ”The provider(s) of DSME will document an organizational structure, mission statement, and goals. For those providers working within a larger organization, that organization will recognize and support quality DSME as an integral component of diabetes care.”

This is a powerful standard in any profession, but from practical knowledge, this is the first standard violated by most providers (CDEs). There are a few that do have this in place and do make use of it for the intended purpose. I am aware of one diabetes clinic in a Midwest city that has something like this on file and all new personnel are required to read this and agree with it before an interview even takes place. In addition, some of the literature handed out by the clinic includes parts of this document. CDEs that fall short of this or violate it are dismissed rather quickly. This is not my clinic, but one in a city about three hours distant depending on the traffic.

Another clinic also has a similar documentation, but this one was written by the doctors that own the diabetes clinic and it works very well. As to how it conforms to the above standard, I can only guess, but a relative of mine does say that she receives excellent education in all areas except nutrition. Since she is a retired nutritionist, she has learned not to include dietitians on her team.

The second standard states, “The provider(s) of DSME will seek ongoing input from external stakeholders and experts in order to promote program quality.”

This is a standard that depends on the office, clinic, or hospital. Some doctors prefer their input only, while others want their CDEs out in the community and participating in community meetings and after work activities. One primary care physician does have his CDEs involved with the school system and checking that pupils with diabetes are receiving proper care. When it was discovered that the school system had made a budget cut to eliminate the nurses, he went before the school board and warned them that they had better reinstate the cut or have the ADA investigating as well as the state board of education. It was reinstated at the next meeting and the two nurses rehired.

Some diabetes clinics do work to have input from the community and have proper channels for other input. I am not aware of any formal advisory boards, but they may exist and I don't know about them.

The third standard states, “The provider(s) of DSME will determine who to serve, how best to deliver diabetes education to that population, and what resources can provide ongoing support for that population.”

Ouch! It is no wonder there is widespread discrimination in the service provided. In many areas, this has to be the reason people with type 2 diabetes don't have CDEs available to them and receive no education about diabetes. Yes, even the standards authors recognize this and state, “Currently, the majority of people with diabetes and prediabetes do not receive any structured diabetes education.”

It is interesting the follow up statement the standards people make. Without the qualified people to be available, this just points out the fact that lay people need training to fill in gaps where CDEs are not available.

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