February 20, 2013

National Standards for DSME and DSMS – Part 1

Part 1 of 6 Parts

When I first started reading this, my thought was to bypass it and maybe consider this later, if at all. Something made me come back and read some parts, and ouch! I must say my wife was surprised and asked me what was making me roar with laughter. In reality, this is not funny, but the content and some of the ways they approach different parts do make me wonder.

It starts with the first paragraph. I see these numbers in most sources and can believe that they are realistic as estimates. The algorithms used probably make these numbers more accurate than we realize. Now is where the amusement starts.  The American Association of Diabetes Educators website formerly had listed memberships of about 13,000 members. They have now removed this number for whatever reason and a search of the site does not reveal the membership numbers.

With 18,800,000 people with diabetes and 13,000 CDEs (certified diabetes educators), this means that allotting one hour per patient would mean seeing 1,446 different patients per year and having 594 patients they could see twice a year. This is figured on a 2,040 hour work year and allowing 80 hours for vacation or two weeks. Now we know these numbers are not realistic as many patients are seen four times per year, or more. We don't know how many CDEs only work part-time, how many are not doing actual educator work, how many are retired, how many are in administration, and other numbers writing books and going on speaking tours. We know that most people with type 2 diabetes never even see a CDE, therefore we have to question if the CDE membership numbers are realistic. This says nothing about many rural areas of the USA where no CDEs live.

I did not include the seven million people that are estimated with undiagnosed diabetes because the CDEs would not be seeing them. Nor will I include any of the estimated 79 million people said to have elevated risk of type 2 diabetes. Then for the people on the “Task Force” for developing the standards to make this statement, “Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and those at risk for developing the disease,” (bold is my emphasis) really makes me laugh as many CDEs do not even teach DSME. They seem to prefer mandates and mantras to doing an actual assessment and developing an education plan based on any assessment.

Until the AADE starts a division for peer-to-peer workers and peer mentors and gives them some of the skills needed, there will not be sufficient people to use DSME or give DSMS (diabetes self-management support) to the people with type 2 diabetes, much less those at risk for developing the disease. The standards have high ideals, but not the personnel to make them work. This is why I needed to laugh to avoid becoming angry.

When I read statements like this blog, and I have to agree with the sentiments expressed, and then along comes a comment like the first comment, it really points out the problems existing in our healthcare system. It also points out the problems in the CDE profession and their attitude about people with type 2 diabetes. I am not denying that people with type 1 diabetes may need more education and support than many people with type 2 diabetes. For people to say that endocrinologists should be exclusively for people with type 1 diabetes is not realistic. More people with type 2 diabetes are finding out that insulin works for them and has less side effects than many of the oral medications. They also need the education and support.

If you are concerned about peer-to-peer workers, peer mentors, and think I am pushing my own agenda, read this by the Standards Task Force.

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?”

Yes, this is one of my aims and I am happy to see the Task Force suggesting that it be researched. While it is being researched, it needs to be acted on now as the number of people developing diabetes will continue to grow and the numbers of CDEs is not growing at a pace to keep up.

As for research on the influence of organizational structure on the effectiveness of the provision of DSME and DSMS, all we need to do is look at what has happened with DSME in the past. The organizational structure may be there at the upper levels, but at the practicing levels, there is no support for it except from rare individuals. There is also little research and support for DSME for the elderly as many CDEs will not work with them and consider this a waste of time since these people are no longer contributors to society. I have written about this here and here. It will remain to be seen if they will consider the value many of these elderly people could contribute as peer workers. Just don't hold your breath waiting for this to happen.

I would urge everyone to take the time to read the National Standards to be able to understand what may be possible. I would also encourage this so that if allowed, we are ready for an intelligent dialog and if denied this, as a way to hold the feet of the CDEs (including the AADE) to the fire. This may be only one of the ways we can break the exclusionary lock they presently have and are still very much trying to hold onto by keeping lay people out.

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