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Community health workers: Where do they fit in the diabetes care team?
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Regardless of how much time we spend teaching our patients the ins and outs of diabetes management, we know that when they leave our offices they return to their routines, families, workplaces and communities. Our patients face numerous social and personal pressures that we cannot counteract in a single diabetes education session.
Ultimately, patients are responsible for their own health; they are the ones who must make the behavior changes necessary to live successfully with diabetes. But to do that, they must have access to the knowledge and services provided by a multidisciplinary diabetes care team.
The team approach to providing diabetes care and education is being adopted broadly across the health care system. This widespread acceptance has given rise to several questions: Who is qualified to teach patients about self-management? Who should be included in the diabetes care team? How do we distinguish between high-quality educational practices and those that are not effective? What duties should a diabetes educator be expected to fulfill?
Because many diabetes education programs recognize that the complex nature of diabetes management extends beyond the walls of the clinic, office or program, an effort has been made to engage people in the community to encourage healthy behaviors and advocate prevention strategies on a local, personal level. These individuals have been collectively referred to as community health workers (CHW), and there has been much debate as to their role and place in the diabetes care continuum.
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Expanding the diabetes care team
The American Association of Diabetes Educators has been systematically developing the documents that provide the infrastructure for the expansion of the diabetes care team and describe a more standardized role for individuals such as CHWs, who are not health care professionals but can support and reinforce healthy lifestyle choices for individuals with diabetes.
The basic education team is defined in the National Standards for Diabetes Self-Management Education, and this concept is expounded upon in the AADE Guidelines for the Practice of Diabetes Self-Management Education and Training. These guidelines clarify and describe the roles and responsibilities of all those involved in the facilitation or delivery of diabetes education and care across a continuum of clinic- and community-based settings.
The guidelines outline the various levels of practitioners and detail at what level they can be involved with assessing patients, helping them set goals, facilitate planning and implementation and participate in monitoring/evaluating the patient’s progress.
Provider levels for diabetes education:
- Level 1: Non-health care professionals
- Level 2: Health care professional/non-diabetes educator
- Level 3: Non-credentialed diabetes educator
- Level 4: Credentialed diabetes educator
- Level 5: Advanced level diabetes educator/clinical manager
Competencies for Diabetes Educators serves as a companion document to the guidelines and further details the essential knowledge and skills that must be demonstrated at each provider level.
Duties of level 1 providers
A soon-to-be-released AADE white paper, titled “A sustainable model of diabetes self-management education and training involves multiple members of the diabetes education team,” takes on the issue of CHWs and asserts that, as level 1 providers, CHWs can provide nonclinical instruction under the direction of a qualified diabetes health care professional.
Level 1 providers may have specific duties in the assessment of patients, goal setting, planning and implementation of a diabetes care plan. They may also focus on practical problem-solving, advocacy and assistance with obtaining access to care, services, medications, etc. The white paper also offers several scenarios and concepts that incorporate level 1 providers into the diabetes care team.
As previously expressed in a 2009 position statement, AADE said the development and training of CHWs should be encouraged, and with adequate training and direction, these individuals can serve as a valued resource to patients while extending the reach of the diabetes educator.
As health care professionals, we understand the need for additional support for our patients. We need the involvement of families, communities and other health advocates to collectively raise the awareness of healthy behaviors and, ultimately, combat the rise in diabetes in our country. CHWs can serve as our allies and collaborators, but there is a need for the proper training of these individuals and a more standardized role for them to fill on the diabetes care team.
Deborah Fillman, MS, RD, LD, CDE, is President of American Association of Diabetes Educators.